?Mathematical formulae have been encoded as MathML and are displayed in this HTML version using MathJax in order to improve their display. Uncheck the box to turn MathJax off. This feature requires Javascript. Click on a formula to zoom.ABSTRACT
This study aimed to investigate the knowledge about, attitudes toward, and acceptance and predictors of receiving the mpox vaccine among Chinese cancer patients. Patients were selected using a convenience sampling method. A web-based self-report questionnaire was developed to assess cancer patients’ knowledge, attitudes, and acceptance regarding the mpox vaccine. Multivariate logistic regression analysis was used to determine predictors of acceptance of the mpox vaccine. A total of 805 cancer patients were included in this study, with a vaccine hesitancy rate of 27.08%. Approximately 66% of the patients’ information about mpox and the vaccine came from the mass media, and there was a significant bias in the hesitant group’s knowledge about mpox and the vaccine. Multivariable logistic regression analysis suggested that retirement; chemotherapy; the belief that the mpox vaccine could prevent disease, that vaccination should be compulsory when appropriate and that the mpox vaccine prevents mpox and reduces complications; the willingness to pay for the mpox vaccine; the willingness to recommend that friends and family receive the mpox vaccine; and the belief that the mpox vaccine should be distributed fairly and equitably were factors that promoted vaccination. The belief that mpox worsens tumor prognosis was a driving factor for vaccine hesitancy. This study investigated the knowledge of cancer patients about mpox and the vaccine, evaluated the acceptance and hesitancy rates of the mpox vaccine and examined the predictors of vaccination intention. We suggest that the government scientifically promote the vaccine and develop policies such as free vaccination and personalized vaccination to increase the awareness and acceptance rate of the mpox vaccine.
Introduction
Currently, the unexpected outbreak of mpox has caused concern for global health systems.Citation1 After 39 years of no reported cases in Nigeria, mpox reemerged in Bayelsa state in 2017 and spread worldwide in 2018.Citation2 Since 1 January 2022, 115 member states from all six WHO regions have reported cases of mpox to the World Health Organization (WHO). As of 30 September 2023, a total of 91,123 laboratory-confirmed cases and 663 probable cases, including 157 deaths, have been reported to the WHO.Citation3
Mpox belongs to the genus Orthopoxvirus of the family Poxviridae and is oval or brick-shaped with a size of approximately 200–250 nm. Poxviruses produce two infectious viral particles during replication.Citation4 Viral particles are transmitted by contact with infected skin, body fluids, or respiratory droplets. The virus is transmitted by oronasopharyngeal fluid exchange or intradermal injection; it then replicates rapidly at the site of inoculation and spreads to adjacent lymph nodes. mpox begins with systemic symptoms, including fever, chills, headache, muscle pain, back pain, and fatigue,Citation5 followed by multiple papules, blistering pustules, ulcerative lesions on the face and body and enlarged lymph nodes, with complications including pneumonia, encephalitis, keratitis, and secondary bacterial infections.Citation6
Most patients with mpox infection recover without medication, and they need only some supportive treatment.Citation7 For patients with severe disease or immunodeficiency, antiviral drugs can be considered.Citation8 Currently, three antiviral drugs, tecovirimat, brincidofovir, and cidofovir, as well as intravenous pox vaccinia immune globulin, are used for the treatment of mpox and its complications,Citation9–11 but the effectiveness of these drugs has not been thoroughly confirmed. Regarding vaccines, relevant data suggest that previous smallpox vaccination may be protective against mpox and may alleviate the clinical manifestations of the infection.Citation12 According to the CDC, the long incubation period of mpox would be expected to prevent mpox if administered within four days of exposure to the mpox vaccine. In clinical practice, generally speaking, smallpox vaccination can provide some protection against mpox.Citation13,Citation14 Currently, two vaccines against mpox, ACAM2000 and JYNNEOS, have been approved in the United States.Citation15 Immunocompromised populations, as well as children, elderly individuals, and pregnant women, are more susceptible to mpox infection, and more attention should be given to such groups. Cancer patients have multiple immunodeficiencies and are more susceptible to injury from infectious disease complications.Citation16 Due to the lack of data on the safety and efficacy of vaccination in cancer patients, there are no clinical guidelines on whether cancer patients should be vaccinated with the mpox vaccine. However, according to studies related to mpox vaccines and cancer patients, the benefits of vaccination for cancer patients may far outweigh the risk of vaccine-related adverse events, and cancer patients should receive priority vaccination for high-quality cancer treatment.Citation17,Citation18 Given the current shortage of mpox vaccines, cancer patients should probably also be prioritized for mpox vaccination to reduce their risk of disease and mitigate complications to protect their health and lives.
Although vaccination is considered one of the most successful public health interventions, at the present time of the COVID-19 epidemic, vaccine hesitancy has reached new levels, and hesitancy about vaccines often coincides with new information, new policies, or newly reported vaccine risks.Citation19 Therefore, interventional education campaigns that target populations at risk of vaccine hesitancy to combat misinformation and avoid low vaccination rates are urgently needed.Citation20 In vaccination efforts, cancer patients are more prone to vaccine hesitancy than the general population, and this problem is common worldwide.Citation21,Citation22
For the mpox vaccine, no data related to vaccine hesitancy have been reported worldwide, but vaccination efforts have been initiated in several countries. To understand the concerns and hesitancy of cancer patients regarding mpox vaccination, we conducted an online survey among cancer patients in China to document the awareness and attitudes of the cancer population regarding mpox vaccines. The expectation is that such work will lay the foundation for possible subsequent domestic vaccination efforts and provide some assistance to vaccination efforts in other countries.
Methods and materials
Study design and participants
This was a web-based, anonymous, cross-sectional study conducted using Questionnaire Star. Questionnaire Star is an electronic questionnaire software that helps to generate, distribute and collect electronic questionnaires. From 15 July 2023 to 15 August 2023, a self-report questionnaire was distributed to cancer patients in five hospitals in Shanghai City, Anhui and Jiangxi Province. All five hospitals are tertiary A-level hospitals, with three located in Shanghai and the others in the provincial capital cities of Jiangxi and Anhui provinces, hence the majority of the questionnaires were distributed in Shanghai. Cancer patients over the age of 18 were invited to participate in this study, and patients with cognitive impairment were excluded. All participants were informed of the purpose of this study, the study procedures, and their rights prior to participation. In addition, all participants were informed that only anonymous data would be used in this study. Verbal consent was obtained from all participants.
Sample size estimation
We estimated the sample size assuming an inoculation rate of 50.6% based on a previous study.Citation23 The sample size was calculated using the following formula:
where n = the number of samples, Z2 = 1.962 (95% confidence level), p = 50.6%, and e = the precision limit or proportion of sampling error (0.04), considering that the study nonresponse rate was estimated to be 5%, and the minimum sample size was 620.
Questionnaire
The self-report questionnaire was developed with reference to previous similar studies on the mpox vaccine and combined with our team’s previous work.Citation24 To assess the knowledge of the participating population about the mpox and mpox vaccines, their attitudes toward the vaccine and their acceptance of the vaccine, the questionnaire was initially developed in English and then translated into Chinese for completion. Finally, it was translated back into English to ensure compatibility.
Ethical approval
This study was approved by the Medical Ethics Committee of Chaohu Hospital of Anhui Medical University (No. KYXM-202207-004). All respondents were informed of the study purpose, procedure, and their relevant rights. They were also informed that their personal identity or information would not be disclosed. Oral informed consent was obtained from each respondent before distribution of the questionnaire.
Statistical analyses
This study used SPSS version 23.0 for data analysis. Sociodemographic characteristics as well as participants’ responses to the questionnaire were uniformly defined as categorical data and expressed as numbers and percentages. A chi-square test was used to assess the relationship between the independent variables (basic information, knowledge of mpox, knowledge of the mpox vaccine, and attitude toward the mpox vaccine) and the outcome variable (participants’ willingness to vaccinate). Variables with p < .05 in the chi-square test were included in multivariable logistic regression analyses to identify variables associated with participants’ willingness to be vaccinated against mpox. For those variables included in the multivariable logistic regression analysis, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were reported, and p < .05 was considered statistically significant.
Results
Characteristics of participants
A total of 820 cancer patients were invited to participate in the questionnaire survey, among which 15 patients returned incomplete questionnaires. Finally, a total of 805 patients completed the survey, for an overall response rate of 98.2%.
Analyzing the results, 24.5% (197/805) of patients were very willing to receive the mpox vaccine, and 48.5% (390/805) of patients were probably willing to receive it. The vaccine acceptance rate was 72.9%. Conversely, 15.3% (123/805) of patients were probably unwilling, and 11.8% (95/805) of respondents were very unwilling to receive the mpox vaccine. The total vaccine hesitancy rate was 27.1% ().
Figure 1. The intention to receive monkeypox vaccine (N = 805).
According to the statistical results of the demographic factors, there was a statistically significant difference between the vaccine hesitancy group and the vaccine acceptance group in terms of age, marital status, residence, occupational status, and current alcohol consumption status (p < .05, ). There were statistically significant differences in the time of cancer diagnosis, ongoing treatment, current disease status, and complication status (p < .05, ).
Table 1. Demographic characteristics of participants.
Table 2. Clinical features of participants.
Knowledge about and attitude toward mpox
In the survey of knowledge about and attitude toward mpox, there was a significant difference between the vaccine hesitancy and vaccine acceptance groups (p < .05, ). About 48.2% of the hesitant group feared mpox, and 55.5% of the hesitant group thought they were at low risk of contracting mpox. Moreover, 67.4% of the vaccine hesitancy group believed that mpox was not preventable. About 60.6% of them thought that mpox could be eliminated worldwide. A total of 71.6% of the hesitant group thought that protection measures in China could prevent mpox, which was much lower than the 95.6% of the acceptance group. Protection measures in China have included a series of measures such as strengthening screening of mpox at entry points, conducting 21-day quarantine observation on close contacts, enhancing animal protection and control measures, and conducting regular disease outbreak checks and reporting.
Table 3. Participants’ attitude toward the mpox.
Knowledge about and attitude toward the mpox vaccine
For the cancer patients in this study, the most frequent source of information about the mpox vaccine was the media (531/805; 66.0%), followed by government agencies (282/805; 35.0%) and friends and family (247/805; 30.7%), while only a small proportion of participants received information about the mpox vaccine from lectures (162/805, 20.1%) or books (144/805, 17.9%) ().
Figure 2. The sourse of information about mpox vaccnine (N=805).
As shown in , there was a significant difference between the vaccine hesitancy and acceptance groups in terms of their knowledge and attitudes toward the mpox vaccine (p < .01). About 58.7% of the vaccine hesitancy group believed that the mpox vaccine could reduce the rate of mpox infection and its complications compared to 85.4% of the acceptance group (p < .001). At the same time, the vaccine hesitancy group had more concerns about vaccine effects, safety, and efficacy; they were more inclined to believe that the vaccine causes allergies as well as other immune diseases. More importantly, 75.7% of the hesitant group believed that the mpox vaccine promoted tumor progression, which was higher than the 58.3% of the acceptance group (p < .001). The vaccine hesitancy group showed extreme resistance to paying for the mpox vaccine (198/213, 88.5%). At the same time, compared to the acceptance group, the hesitancy group has slightly lower recognition of the importance of the vaccine, but deep down they still lean towards supporting the fair distribution of the mpox vaccine (149/213,68.4%). At the same time, they did not want their family members or friends to be vaccinated.
Table 4. Participants’ attitude toward the mpox vaccine.
Reasons for willingness or unwillingness to get the mpox vaccine
When we further analyzed the specific reasons for willingness to get mpox vaccinated. 76.7% of the respondents reported that they thought the vaccine has protective effect against mpox, 56.4% believed that the benefits of vaccination that outweighed the risks, and 53.5% considered that vaccination is a social responsibility ().
Figure 3. The reasons for willingness to get mpox vaccinated (N = 587).
For the reasons why 218 respondents were unwilling to get mpox vaccinated, 84.4% of the respondents feared that the vaccine would affect tumor treatment or process, 71.6% feared the adverse reactions to the vaccine, and 64.2% doubted about the safety of the vaccine ().
Figure 4. The reason for unwillingness to get mpox vaccinated (N=218).
Predictors of mpox vaccine attitudes
In the univariate analysis, there were 27 variables with p < .05 (chi-square test, ). A multivariable logistic regression analysis of these 27 variables showed that 9 variables significantly influenced the willingness of cancer patients to receive the mpox vaccine ().
Table 5. Predictors of intention to receive mpox vaccine.
As shown in , being retired (OR = 2.21,95% CI: 1.11–4.41); receiving chemotherapy (OR = 4.48,95% CI: 1.80–11.16); believing that mpox could be prevented (OR = 2.72,95% CI: 1.26–5.85); believing that vaccination should be compulsory (OR = 2.14,95% CI: 1.26–3.65); believing that vaccines could reduce the risk of mpox infection and complications (OR = 1.88,95% CI: 1.07–3.30); being willing to pay for the vaccine (OR = 4.63, 95% CI: 2.62–8.18); being willing to encourage friends and family to get the mpox vaccine (OR = 2.86, 95% CI: 1.66–4.92); and believing that the mpox vaccine should be distributed fairly (OR = 2.02, 95% CI: 1.09–3.74) were all positive factors that promoted vaccination. Additionally, the belief that the vaccine might worsen the prognosis of cancer (OR = 0.37, 95% CI: 0.20–0.78) was an important reason for vaccine hesitancy.
Discussion
A large proportion of mpox cases have been reported since 13 May 2022 from countries with no previous record of mpox transmission. At this point, a vaccine is extremely important.Citation25
Current studies suggest focusing on the possibility of mpox outbreaks in susceptible populations and among children, pregnant women, and immunocompromised individuals, whose vaccine use needs more research. However, cancer patients tend to have higher levels of hesitancy to receive vaccines, and elucidating the sources of their hesitancy and the factors influencing it is important to promote vaccination. This study provides preliminary insights into the predictors of intention to receive the mpox vaccine among Chinese cancer patients. It is also the first study of its kind worldwide. A total of 805 cancer patients were included in this study, with a vaccine hesitancy rate of 27.08%. Approximately 66% of the patients’ information about mpox and the mpox vaccine came from the mass media, and there was a significant bias in the hesitant group’s knowledge about mpox and the vaccine. Multivariable logistic regression analysis suggested that retirement; chemotherapy; the belief that the mpox vaccine could prevent disease, that vaccination should be compulsory when appropriate and that the mpox vaccine prevents mpox and reduces complications; the willingness to pay for the mpox vaccine; the willingness to recommend that friends and family receive the mpox vaccine; and the belief that the mpox vaccine should be distributed fairly and equitably were factors that promoted vaccination. The belief that mpox worsens tumor prognosis was a driving factor for vaccine hesitancy. Based on the results of this study, we make the following recommendations.
Determining the safety and efficacy of vaccines and their effect on tumor progression would be important for vaccination promotion in cancer patients
This study suggested that approximately 27% of cancer patients showed hesitation to mpox vaccination. Univariate analysis suggested that there were differences in perceptions between the hesitancy and acceptance groups regarding the safety of the mpox vaccine, the efficacy of the mpox vaccine, the possible immune diseases caused by the mpox vaccine, and the possible impact of the mpox vaccine on tumor treatment, with the hesitant group having more negative attitudes. In multivariable logistic regression, the fear of worsening tumor prognosis with the mpox vaccine was the main predictor of vaccine hesitancy (). What is puzzling is that single-factor concerns about safety and efficacy did not play a significant role in the multivariable logistic regression. This may be because the comprehensive promotion of COVID-19 vaccination in China in the past few years has somewhat altered people’s perceptions of vaccines Citation26,Citation27. However, for cancer patients, whether the vaccine will cause tumor progression may be their foremost concern, surpassing considerations of safety and efficacy. But this does not mean that safety and effectiveness are unimportant.
In a meta-analysis of vaccine hesitancy among cancer patients regarding the COVID-19 vaccine, which included 27 studies, concerns about vaccine-related side effects, uncertainty about vaccine efficacy and safety, aggressive antitumor therapy, and doubts about rapid vaccine development were found to be the main reasons for vaccine hesitancy.Citation28 This suggests that cancer patients’ concerns about vaccine safety, efficacy, and side effects are common issues. To address cancer patients’ concerns about the safety and efficacy of the mpox vaccine, clear and credible communication must be encouraged to address patient misperceptions and specific questions.Citation29 The active involvement of oncologists and epidemiologists is essential to educate cancer patients about the benefits of vaccination and to support vaccination.Citation30 In addition, it is important that individualized strategies for vaccination of cancer patients be made available to patients, which requires adequate consideration of the cancer patient’s disease status as well as current treatment strategies.Citation31
Professional public information guidance and policy engagement are important tools to encourage patient acceptance of vaccines
This study found that the largest source of information about the mpox vaccine for cancer patients was the media (531/805; 65.96%), followed by government agencies (282/805; 35.03%) and friends and family (247/805; 30.68%), and nearly twice as many patients received information from the media as from government agencies. However, the uneven quality of media information about vaccines and the lack of involvement of medical professionals make improving vaccination a tremendous public health challenge.Citation32,Citation33 Multivariable logistic analysis suggested that the belief that mpox could be prevented and the belief that the mpox vaccine could reduce mpox infection and mpox complications were positive factors promoting mpox vaccination (). Therefore, people should actively disseminate knowledge about mpox and accurate information about the risks and benefits of vaccination to combat misinformation. This requires well-designed media campaigns provided by trusted institutions and linked to professional medical structures.Citation34
Moreover, to promote vaccination, the government needs to provide appropriate policy support. On the one hand, a free mpox vaccine needs to be provided to cancer patients. In the survey, about 49.1% of the respondents were willing to pay for the vaccine, less than half. Willingness to pay is an important factor affecting cancer patients’ willingness to get vaccinated. Nearly half of Chinese cancer patients face serious financial problems or even cancer-related debts.Citation35,Citation36 People with greater personal financial or family burdens are more hesitant about vaccines.Citation37 In the context of the mass free distribution of the COVID-19 vaccine, the rollout of the mpox vaccine must be hampered if it requires a fee. In this context, we found that in several countries worldwide, including the United States, France, and Switzerland, the distribution of the mpox vaccine is free of charge, which is worth promoting and learning from.
In previous studies, vaccine accessibility and cost were found to be important factors for participants to consider before deciding to get vaccinated.Citation38 The present study found that cancer patients who supported a fair and equitable distribution of vaccines had higher vaccine acceptance (). According to the recommendations of the Advisory Committee on Immunization Practices for equitable distribution, minimizing harm and maximizing benefits, promoting justice, mitigating health inequities, and promoting transparency are important.Citation39 It is necessary and valuable for cancer patients, as a socially vulnerable group, to have access to fair and equitable prioritization of vaccines, which requires appropriate governmental guidelines.
Individualized vaccination programs for cancer patients with different demographic characteristics
According to the results of this study, the occupational status of cancer patients, the nature of the treatment they were receiving, and their personal knowledge and attitudes toward mpox and mpox vaccines were factors that influenced their acceptance of the vaccine (). The personal status of cancer patients is closely related to their willingness to vaccinate. Therefore, individualized recommendations combined with the personal status of cancer patients are more appropriate to convince cancer patients to receive the vaccine. For example, retired cancer patients in rural areas, for whom there is no current work demand, less contact with the outside world, and less population mobility in rural areas, do not have the urgency or necessity of mpox vaccination; rather, the potential side effects of the mpox vaccine may overwhelm the benefits of the vaccine in this population. In contrast, priority vaccination should be considered for patients who are in a stable stage of cancer treatment, do not have allergic diseases, work in jobs with a risk of mpox exposure, or are homosexual.Citation40 However, there are no international guidelines related to the use of the mpox vaccine for cancer patients, and more research is needed to demonstrate the safest circumstances for mpox vaccination among cancer patients.
Multicountry, multiregion, and multipopulation large-sample surveys will help improve vaccine promotion
Although this is the first global survey of cancer patients’ knowledge, attitudes and willingness to receive the mpox vaccine, there are still some shortcomings in this study due to the lack of time and human and material resources in the context of recurrent COVID-19 epidemics.
First, to ensure the quality of questionnaire completion, the questionnaire was distributed by an electronic platform used by medical professionals and completed in a limited time window; therefore, only a small-scale distribution was conducted, but our team is already preparing for a second round of a larger survey, which will be further supplemented in the follow-up. Second, because this study was only conducted in three regions of China, namely, Shanghai City, Anhui and Jiangxi Province, it could not represent the full situation of patients in all regions of China. Future research will incorporate a more comprehensive and inclusive sample in anticipation of enhancing the generalizability and reflectiveness of the findings to more accurately represent the wider cancer patient population. Finally, this was a cross-sectional study, and no causal relationship could be inferred. Further longitudinal studies are needed to confirm our findings. At the same time, limited by the conditions of the survey, random sampling was not used, and the representativeness of the sample was insufficient. In a follow-up study, we will expand the study area and the study population using stratified sampling and other methods and look forward to further exploring the relationship between participant characteristics and vaccine hesitancy to better elucidate the concerns of cancer patients and make efforts to promote the mpox vaccine.
Conclusion
This study revealed the knowledge, attitudes, and willingness of Chinese cancer patients to receive the mpox vaccine. The vaccine hesitancy rate was 27%, and the main reason for vaccine hesitancy was concern that the vaccine might worsen the prognosis of cancer treatment; however, retirement, treatment with chemotherapy, belief that mpox is preventable, belief that the mpox vaccine can prevent mpox and reduce complications, willingness to pay for the vaccine, and willingness to recommend that friends and family receive the vaccine were all factors that promoted vaccine uptake.
In terms of increasing vaccine acceptance, we recommend that government agencies take the lead in working with professional medical teams to deliver correct and complete vaccine information to the public through multiple media outlets and to provide free vaccines to underserved groups. Further clinical studies are needed on mpox vaccination for cancer patients, but personalized vaccination recommendations based on the individual circumstances of cancer patients, including disease status, treatment received, and living environment, are valuable and easily accepted.
Author contributions
JD, XCL and JH designed the study. CQY and QMZ reviewed the experimental design and suggested improvements. JD, YQL and XWX were responsible for data collection. JD and XCL performed data analyses. All authors participated in data interpretation, manuscript review and writing. JD XCL and JH were responsible for preparation of the Tables and Figures. JD and CQY were responsible for completing the manuscript. All authors contributed to the discussion of the data and of the manuscript.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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