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Disruption of childhood vaccination during the COVID-19 pandemic in Indonesia Marhami Fahriani; Samsul Anwar; Amanda Yufika; Bakhtiar Bakhtiar; Elly Wardani; Wira Winardi; Kaitlyn B. Akel; Abram L. Wagner; Harapan Harapan
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.7

The aim of this study was to assess the magnitude of childhood vaccination disruption and to determine the predictors of delaying childhood vaccinations during the coronavirus disease 2019 (COVID-19) pandemic among Indonesian parents. We conducted a nationwide, online, cross-sectional study. A set of questionnaires assessed the disruption of childhood vaccinations and possible explanatory variables, including demographic characteristics, current underlying disease, exposure to and confidence in COVID-19 information, perceived risk, attitude and practice on vaccination, and COVID-19 prevention practice. A multivariable linear regression was used to characterize the relationship between explanatory variables and delayed childhood vaccination. We included 1137 respondents for analysis, of which 52.6% were males and 58.4% participants aged between 31 and 50-years old. Disruption of childhood vaccination service in local health facilities was reported in 42.2% (480/1137) of respondents and 13.3% (193/1137) of respondents explained that their children could not be vaccinated because a healthcare facility temporary stopped the vaccination service. Of all respondents, 312 (27.4%) delayed vaccinating their children for a compulsory vaccination shot. Factors associated with higher odds of delaying compulsory vaccinations for children were employment and chronic disease status, flu vaccination status in the past year, and prior COVID-19 infection. In conclusion, there was a significant disruption of childhood vaccination practices in Indonesia during the COVID-19 pandemic. This is not only due to healthcare closures but also due to parents’ practice - delaying the compulsory childhood vaccination for their children. We urge the government to strengthen strategies to ensure childhood vaccination services are available to all children in the country during a pandemic.

Decline of notified dengue infections in Indonesia in 2017: Discussion of the possible determinants Pandji Wibawa Dhewantara; Kurnia F. Jamil; Jonny Karunia Fajar; Panji Probo Saktianggi; Roy Nusa; Triwibowo Ambar Garjito; Samsul Anwar; Firzan Firzan; Dewi Megawati; R. Tedjo Sasmono; Mudatsir Mudatsir
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.23

This study was conducted to quantify the trend in dengue notifications in the country in 2017 and to explore the possible determinants. Annual nation-wide dengue notification data were obtained from the National Disease Surveillance of Ministry of Health of Indonesia. Annual incidence rate (IR) and case fatality rate (CFR) in 2017 and the previous years were quantified and compared. Correlations between annual larva free index (LFI), implementation coverage of integrated vector management (IVM), El Niño Southern Oscillation (Niño3.4), Dipole Mode Index (DMI), Zika virus seropositivity and the percent change in IR and CFR of dengue were examined. The change of dengue IR and CFRs were mapped. In 2017, dengue IR was declined by 71% (22.55 per 100,000 population) compared to 2016 (77.96 per 100,000 population) while the CFR was slightly reduced from 0.79% to 0.75%. Reduction in IR and CFR occurred in 94.1% and 70.1% out of 34 provinces, respectively. The trend of dengue IR seems to be influenced by Niño3.4 but there is no clear evidence that Niño3.4 is the main reason for dengue reduction in 2017. It is difficult to elucidate that the reduction of dengue in 2017 was associated with previous Zika outbreaks. In conclusion, there was a significant reduction on dengue notifications in Indonesia in 2017. Further investigation is needed to look at the role of climate on the decline of dengue IR at finer temporal scale. In addition, study on the role of cross-protective immunity generated by Zika infection on dengue incidence is also warranted.

Attitude towards Zika among frontline physicians in a dengue-endemic country: A preliminary cross-sectional study in Indonesia Amanda Yufika; Samsul Anwar; Reza Maulana; Nur Wahyuniati; Rizki R. Ramadana; Ikram Ikram; Mudatsir Mudatsir; Prattama S. Utomo; Haypheng Te; Seyi Samson Enitan; Salin Sirinam; Ruth Müller; Abdul Malik Setiawan
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.32

In dengue-endemic countries such as Indonesia, Zika may be misdiagnosed as dengue, leading to underestimates of Zika disease and less foreknowledge of pregnancy-related complications such as microcephaly. Objective: To assess the attitudes of frontline physicians in a dengue-endemic country toward testing for Zika infection among patients with dengue-like illnesses. Methods: A cross-sectional online survey was conducted among general practitioners (GPs) in Indonesia. The survey assessed their attitude and also collected sociodemographic data, characteristics of their medical education, professional background, and workplace, and exposure to Zika cases. A two-step logistic regression analysis was used to assess possible variables associated with these attitudes. Results: A total of 370 GPs were included in the final analysis of which 70.8% had good attitude. Unadjusted analyses suggested that GPs who were 30 years old or older and those who had medical experience five years or longer had lower odds of having a positive attitude compared to those who aged younger than 30 years and those who had medical experience less than five years, OR: 0.58; 95%CI: 0.37, 0.91 and OR: 0.55; 95%CI: 0.35, 0.86, respectively. No explanatory variable was associated with attitude in the fully adjusted model. Conclusion: Our findings point to younger GPs with a shorter medical experience being more likely to consider testing for Zika infection among their patients presenting with dengue-like illnesses. Strategic initiatives may be needed to enhance older or longer-experienced physicians' capacity in diagnosing Zika infection.

Acceptance of COVID-19 vaccination at different hypothetical efficacy and safety levels in ten countries in Asia, Africa, and South America Dott F. Rosiello; Samsul Anwar; Amanda Yufika; Rashed Y. Adam; Mohajer IH. Ismaeil; Asma Y. Ismail; Nesrine BH. Dahman; Montacer Hafsi; Manel Ferjani; Farah S. Sami; Fatma A Monib; Subramaniam R; Sunil Anandu; Md Ariful Haque; Lirane ED. Ferreto; José TO. Aburto; Jorge ET. Rojas; Seyi S. Enitan; Akele R. Yomi; Eyiuche D. Ezigbo; Elham Babadi; Edris Kakemam; Najma I. Malik; Irfan Ullah; Malik Sallam
Narra J Vol. 1 No. 3 (2021): December 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v1i3.55

Vaccine hesitancy, defined as the reluctance or rejection in receiving a vaccine despite its availability, represents a major challenge to global health efforts aiming to control the ongoing COVID-19 pandemic. Understanding the possible factors correlated with COVID-19 vaccine hesitancy using a refined well-informed approach can be helpful to address the phenomenon. The current study aimed to evaluate COVID-19 vaccine acceptance rates using four hypothetical scenarios of varying levels of vaccine efficacy and safety profiles in ten Asian, African and South American countries. These scenarios included: 95% efficacy and 20% side effects (Vaccine A), 75% efficacy and 5% side effects (Vaccine B); 75% efficacy and 20% side effects (Vaccine C) and 50% efficacy and 5% side effects (Vaccine D). This study used a self-administered online survey that was distributed during February–May 2021. The total number of study respondents was 1337 with countries of residence as follows: India (21.1%), Pakistan (12.9%), Sudan (11.2%), Nigeria (9.3%), Iran (8.2%), Bangladesh and Brazil (7.9%), Chile (7.7%), Tunisia (7.6%), and Egypt (6.2%). The overall acceptance rates for COVID-19 vaccination were variable based on varying degrees of safety and efficacy as follows: 55.6% for Vaccine C, 58.3% for Vaccine D, 74.0% for Vaccine A and 80.1% for Vaccine B. The highest levels of COVID-19 vaccine acceptance were observed in Brazil followed by Chile across the four different safety and efficacy scenarios. The lowest COVID-19 vaccine acceptance rates were reported in Egypt and Tunisia for the low safety scenarios (20% side effects), and the low efficacy scenario (50% efficacy). The study revealed the potential effect of vaccine safety and efficacy on the intention to get COVID-19 vaccination. At the same efficacy level, higher possibility of side effects caused a large drop in COVID-19 vaccine acceptance rate. This indicates the importance of accurate communication regarding vaccine safety and efficacy on attitude towards the vaccine and intentions to get vaccinated. Regional differences in COVID-19 vaccine acceptance were observed with the Middle East/North African countries showing the lowest rates and the South American countries displaying the highest vaccine acceptance rates.

Willingness-to-pay for COVID-19 vaccine in ten low-middle-income countries in Asia, Africa and South America: A cross-sectional study Malik Sallam; Samsul Anwar; Amanda Yufika; Marhami Fahriani; Milda Husnah; Hendrix I. Kusuma; Rawan Raad; Namareg ME. Khiri; Rashed YA. Abdalla; Rashed Y. Adam; Mohajer IH. Ismaeil; Asma Y. Ismail; Wajdi Kacem; Zeineb Teyeb; Khaoula Aloui; Montacer Hafsi; Nesrine Ben Hadj Dahman; Manel Ferjani; Dalia Deeb; Dina Emad; Farah S. Sami; Kirellos Said Abbas; Fatma A. Monib; Subramaniam R; Suhrud Panchawagh; Khan Sharun; Sunil Anandu; Mahir Gachabayov; Md A. Haque; Talha B. Emran; Guilherme W. Wendt; Lirane ED. Ferreto; María F. Castillo-Briones; Rocío B. Inostroza-Morales; Sebastián A. Lazcano-Díaz; José T. Ordóñez-Aburto; Jorge E. Troncoso-Rojas; Emmanuel O. Balogun; Akele R. Yomi; Abiodun Durosinmi; Esther N. Adejumo; Eyiuche D. Ezigbo; Morteza Arab-Zozani; Elham Babadi; Edris Kakemam; Irfan Ullah; Najma I. Malik; Deema Dababseh; Francesco Rosiello; Seyi S. Enitan
Narra J Vol. 2 No. 1 (2022): April 2022
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v2i1.74

Vaccine hesitancy is considered as one of the greatest challenges to control the ongoing coronavirus disease 2019 (COVID-19) pandemic. A related challenge is the unwillingness of the general public to pay for vaccination. The objective of this study was to determine willingness-to-pay (WTP) for COVID-19 vaccine among individuals from ten low-middle-income countries (LMICs) in Asia, Africa, and South America. Data were collected using an online questionnaire distributed during February - May 2021 in ten LMICs (Bangladesh, Brazil, Chile, Egypt, India, Iran, Nigeria, Pakistan, Sudan, and Tunisia). The major response variable of in this study was WTP for a COVID-19 vaccine. The assessment of COVID-19 vaccine hesitancy was based on items adopted from the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) vaccine hesitancy scale constructs. In this study, 1337 respondents included in the final analysis where the highest number of respondents was from India, while the lowest number was from Egypt. A total of 88.9% (1188/1337) respondents were willing to pay for the COVID-19 vaccination, and 11.1% (149/1337) were not. The average WTP for COVID-19 vaccination was 87.9 US dollars ($), (range: $5-$200). The multivariate model analysis showed that the country, monthly household income, having a history of respiratory disease, the agreement that routine vaccines recommended by health workers are beneficial and having received the flu vaccination within the previous 12 months were strongly associated with the WTP. Based on the country of origin, the highest mean WTP for COVID-19 vaccine was reported in Chile, while the lowest mean WTP for the vaccine was seen among the respondents from Sudan. The availability of free COVID-19 vaccination services appears as a top priority in the LMICs for successful control of the ongoing pandemic. This is particularly important for individuals of a lower socio-economic status. The effects of complacency regarding COVID-19 extends beyond vaccine hesitancy to involve less willingness to pay for COVID-19 vaccine and a lower value of WTP for the vaccine.

Disruption of childhood vaccination during the COVID-19 pandemic in Indonesia Fahriani, Marhami; Anwar, Samsul; Yufika, Amanda; Bakhtiar, Bakhtiar; Wardani, Elly; Winardi, Wira; Akel, Kaitlyn B.; Wagner, Abram L.; Harapan, Harapan
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.7

The aim of this study was to assess the magnitude of childhood vaccination disruption and to determine the predictors of delaying childhood vaccinations during the coronavirus disease 2019 (COVID-19) pandemic among Indonesian parents. We conducted a nationwide, online, cross-sectional study. A set of questionnaires assessed the disruption of childhood vaccinations and possible explanatory variables, including demographic characteristics, current underlying disease, exposure to and confidence in COVID-19 information, perceived risk, attitude and practice on vaccination, and COVID-19 prevention practice. A multivariable linear regression was used to characterize the relationship between explanatory variables and delayed childhood vaccination. We included 1137 respondents for analysis, of which 52.6% were males and 58.4% participants aged between 31 and 50-years old. Disruption of childhood vaccination service in local health facilities was reported in 42.2% (480/1137) of respondents and 13.3% (193/1137) of respondents explained that their children could not be vaccinated because a healthcare facility temporary stopped the vaccination service. Of all respondents, 312 (27.4%) delayed vaccinating their children for a compulsory vaccination shot. Factors associated with higher odds of delaying compulsory vaccinations for children were employment and chronic disease status, flu vaccination status in the past year, and prior COVID-19 infection. In conclusion, there was a significant disruption of childhood vaccination practices in Indonesia during the COVID-19 pandemic. This is not only due to healthcare closures but also due to parents’ practice - delaying the compulsory childhood vaccination for their children. We urge the government to strengthen strategies to ensure childhood vaccination services are available to all children in the country during a pandemic.

Decline of notified dengue infections in Indonesia in 2017: Discussion of the possible determinants Dhewantara, Pandji Wibawa; Jamil, Kurnia F.; Fajar, Jonny Karunia; Saktianggi, Panji Probo; Nusa, Roy; Garjito , Triwibowo Ambar; Anwar, Samsul; Firzan, Firzan; Megawati , Dewi; Sasmono, R. Tedjo; Mudatsir, Mudatsir
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.23

This study was conducted to quantify the trend in dengue notifications in the country in 2017 and to explore the possible determinants. Annual nation-wide dengue notification data were obtained from the National Disease Surveillance of Ministry of Health of Indonesia. Annual incidence rate (IR) and case fatality rate (CFR) in 2017 and the previous years were quantified and compared. Correlations between annual larva free index (LFI), implementation coverage of integrated vector management (IVM), El Niño Southern Oscillation (Niño3.4), Dipole Mode Index (DMI), Zika virus seropositivity and the percent change in IR and CFR of dengue were examined. The change of dengue IR and CFRs were mapped. In 2017, dengue IR was declined by 71% (22.55 per 100,000 population) compared to 2016 (77.96 per 100,000 population) while the CFR was slightly reduced from 0.79% to 0.75%. Reduction in IR and CFR occurred in 94.1% and 70.1% out of 34 provinces, respectively. The trend of dengue IR seems to be influenced by Niño3.4 but there is no clear evidence that Niño3.4 is the main reason for dengue reduction in 2017. It is difficult to elucidate that the reduction of dengue in 2017 was associated with previous Zika outbreaks. In conclusion, there was a significant reduction on dengue notifications in Indonesia in 2017. Further investigation is needed to look at the role of climate on the decline of dengue IR at finer temporal scale. In addition, study on the role of cross-protective immunity generated by Zika infection on dengue incidence is also warranted.

Attitude towards Zika among frontline physicians in a dengue-endemic country: A preliminary cross-sectional study in Indonesia Yufika, Amanda; Anwar, Samsul; Maulana, Reza; Wahyuniati, Nur; Ramadana, Rizki R.; Ikram, Ikram; Mudatsir, Mudatsir; Utomo, Prattama S.; Te, Haypheng; Enitan, Seyi Samson; Sirinam, Salin; Müller, Ruth; Setiawan, Abdul Malik
Narra J Vol. 1 No. 1 (2021): April 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narraj.v1i1.32

In dengue-endemic countries such as Indonesia, Zika may be misdiagnosed as dengue, leading to underestimates of Zika disease and less foreknowledge of pregnancy-related complications such as microcephaly. Objective: To assess the attitudes of frontline physicians in a dengue-endemic country toward testing for Zika infection among patients with dengue-like illnesses. Methods: A cross-sectional online survey was conducted among general practitioners (GPs) in Indonesia. The survey assessed their attitude and also collected sociodemographic data, characteristics of their medical education, professional background, and workplace, and exposure to Zika cases. A two-step logistic regression analysis was used to assess possible variables associated with these attitudes. Results: A total of 370 GPs were included in the final analysis of which 70.8% had good attitude. Unadjusted analyses suggested that GPs who were 30 years old or older and those who had medical experience five years or longer had lower odds of having a positive attitude compared to those who aged younger than 30 years and those who had medical experience less than five years, OR: 0.58; 95%CI: 0.37, 0.91 and OR: 0.55; 95%CI: 0.35, 0.86, respectively. No explanatory variable was associated with attitude in the fully adjusted model. Conclusion: Our findings point to younger GPs with a shorter medical experience being more likely to consider testing for Zika infection among their patients presenting with dengue-like illnesses. Strategic initiatives may be needed to enhance older or longer-experienced physicians' capacity in diagnosing Zika infection.

Acceptance of COVID-19 vaccination at different hypothetical efficacy and safety levels in ten countries in Asia, Africa, and South America Rosiello, Dott F.; Anwar, Samsul; Yufika, Amanda; Adam, Rashed Y.; Ismaeil, Mohajer IH.; Ismail, Asma Y.; Dahman, Nesrine BH.; Hafsi, Montacer; Ferjani, Manel; Sami, Farah S.; Monib, Fatma A; R, Subramaniam; Anandu, Sunil; Haque, Md Ariful; Ferreto, Lirane ED.; Aburto, José TO.; Rojas, Jorge ET.; Enitan, Seyi S.; Yomi, Akele R.; Ezigbo, Eyiuche D.; Babadi, Elham; Kakemam, Edris; Malik, Najma I.; Ullah, Irfan; Sallam, Malik
Narra J Vol. 1 No. 3 (2021): December 2021
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v1i3.55

Vaccine hesitancy, defined as the reluctance or rejection in receiving a vaccine despite its availability, represents a major challenge to global health efforts aiming to control the ongoing COVID-19 pandemic. Understanding the possible factors correlated with COVID-19 vaccine hesitancy using a refined well-informed approach can be helpful to address the phenomenon. The current study aimed to evaluate COVID-19 vaccine acceptance rates using four hypothetical scenarios of varying levels of vaccine efficacy and safety profiles in ten Asian, African and South American countries. These scenarios included: 95% efficacy and 20% side effects (Vaccine A), 75% efficacy and 5% side effects (Vaccine B); 75% efficacy and 20% side effects (Vaccine C) and 50% efficacy and 5% side effects (Vaccine D). This study used a self-administered online survey that was distributed during February–May 2021. The total number of study respondents was 1337 with countries of residence as follows: India (21.1%), Pakistan (12.9%), Sudan (11.2%), Nigeria (9.3%), Iran (8.2%), Bangladesh and Brazil (7.9%), Chile (7.7%), Tunisia (7.6%), and Egypt (6.2%). The overall acceptance rates for COVID-19 vaccination were variable based on varying degrees of safety and efficacy as follows: 55.6% for Vaccine C, 58.3% for Vaccine D, 74.0% for Vaccine A and 80.1% for Vaccine B. The highest levels of COVID-19 vaccine acceptance were observed in Brazil followed by Chile across the four different safety and efficacy scenarios. The lowest COVID-19 vaccine acceptance rates were reported in Egypt and Tunisia for the low safety scenarios (20% side effects), and the low efficacy scenario (50% efficacy). The study revealed the potential effect of vaccine safety and efficacy on the intention to get COVID-19 vaccination. At the same efficacy level, higher possibility of side effects caused a large drop in COVID-19 vaccine acceptance rate. This indicates the importance of accurate communication regarding vaccine safety and efficacy on attitude towards the vaccine and intentions to get vaccinated. Regional differences in COVID-19 vaccine acceptance were observed with the Middle East/North African countries showing the lowest rates and the South American countries displaying the highest vaccine acceptance rates.

Willingness-to-pay for COVID-19 vaccine in ten low-middle-income countries in Asia, Africa and South America: A cross-sectional study Sallam, Malik; Anwar, Samsul; Yufika, Amanda; Fahriani, Marhami; Husnah, Milda; Kusuma, Hendrix I.; Raad, Rawan; Khiri, Namareg ME.; Abdalla, Rashed YA.; Adam, Rashed Y.; Ismaeil, Mohajer IH.; Ismail, Asma Y.; Kacem, Wajdi; Teyeb, Zeineb; Aloui , Khaoula; Hafsi , Montacer; Dahman, Nesrine Ben Hadj; Ferjani, Manel; Deeb, Dalia; Emad , Dina; Sami, Farah S.; Abbas, Kirellos Said; Monib, Fatma A.; R , Subramaniam; Panchawagh, Suhrud; Sharun, Khan; Anandu, Sunil; Gachabayov, Mahir; Haque , Md A.; Emran, Talha B.; Wendt, Guilherme W.; Ferreto, Lirane ED.; Castillo-Briones, María F.; Inostroza-Morales, Rocío B.; Lazcano-Díaz, Sebastián A.; Ordóñez-Aburto, José T.; Troncoso-Rojas, Jorge E.; Balogun, Emmanuel O.; Yomi, Akele R.; Durosinmi, Abiodun; Adejumo, Esther N.; Ezigbo, Eyiuche D.; Arab-Zozani, Morteza; Babadi, Elham; Kakemam, Edris; Ullah, Irfan; Malik, Najma I.; Dababseh, Deema; Rosiello, Francesco; Enitan , Seyi S.
Narra J Vol. 2 No. 1 (2022): April 2022
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v2i1.74

Vaccine hesitancy is considered as one of the greatest challenges to control the ongoing coronavirus disease 2019 (COVID-19) pandemic. A related challenge is the unwillingness of the general public to pay for vaccination. The objective of this study was to determine willingness-to-pay (WTP) for COVID-19 vaccine among individuals from ten low-middle-income countries (LMICs) in Asia, Africa, and South America. Data were collected using an online questionnaire distributed during February - May 2021 in ten LMICs (Bangladesh, Brazil, Chile, Egypt, India, Iran, Nigeria, Pakistan, Sudan, and Tunisia). The major response variable of in this study was WTP for a COVID-19 vaccine. The assessment of COVID-19 vaccine hesitancy was based on items adopted from the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) vaccine hesitancy scale constructs. In this study, 1337 respondents included in the final analysis where the highest number of respondents was from India, while the lowest number was from Egypt. A total of 88.9% (1188/1337) respondents were willing to pay for the COVID-19 vaccination, and 11.1% (149/1337) were not. The average WTP for COVID-19 vaccination was 87.9 US dollars ($), (range: $5-$200). The multivariate model analysis showed that the country, monthly household income, having a history of respiratory disease, the agreement that routine vaccines recommended by health workers are beneficial and having received the flu vaccination within the previous 12 months were strongly associated with the WTP. Based on the country of origin, the highest mean WTP for COVID-19 vaccine was reported in Chile, while the lowest mean WTP for the vaccine was seen among the respondents from Sudan. The availability of free COVID-19 vaccination services appears as a top priority in the LMICs for successful control of the ongoing pandemic. This is particularly important for individuals of a lower socio-economic status. The effects of complacency regarding COVID-19 extends beyond vaccine hesitancy to involve less willingness to pay for COVID-19 vaccine and a lower value of WTP for the vaccine.

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