Public perception and correlates of Mpox vaccine acceptability in northern Nigeria: a mixed methods study

¹Division of Epidemiology and Biostatistics, Department of Community Medicine, Bayero University Kano, Kano, Nigeria, ²University of Oxford, Oxford, United Kingdom, ³Kano Independent Research Centre Trust, Kano, Nigeria, ⁴Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Tennessee, United States of America

^&Corresponding author
Zubairu Iliyasu, Division of Epidemiology and Biostatistics, Department of Community Medicine, Bayero University Kano, Kano, Nigeria

Introduction    

Mpox is a zoonotic disease intricately linked to smallpox. The disease was recently renamed Mpox, and it is caused by a double-stranded DNA virus belonging to the Orthopoxvirus of the Poxviridae family [1]. The Mpox virus was first detected in imported monkeys in Denmark in 1958 [2] and subsequently in a 9-year-old boy in the Democratic Republic of Congo (DRC) in 1970 [3]. Interaction with infected wildlife, peri-domestic rodents and squirrels, and bushmeat trade are primary sources of human infection [4]. Human-to-human transmission follows contact with patients, body fluids, respiratory droplets, sexual contact, and vertically. The clinical features of Mpox are similar but milder compared to smallpox. After a 5 to 21-day incubation period, infected persons typically develop fever, generalized headache, enlarged cervical and inguinal lymph nodes, fatigue, back pain, myalgia, and itchy painful centrifugal rashes [5,6]. During the current global outbreak, however, novel features have been reported, including genital rash, severe proctitis, urethritis, and urinary retention in men who have sex with men [7]. Most cases are self-limiting, but about 40% of affected people develop complications including rectal pain, odynophagia, penile oedema, skin and anorectal abscesses, septicemia, encephalitis, myocarditis, bronchopneumonia, corneal ulcers, and blindness [8]. Abortion and stillbirth have also been reported among pregnant women [9]. The case fatality rate ranges from 7% to 10% [8].

Mpox is endemic in Central and West Africa, including Nigeria since the late 1970s. Before the recent global outbreak, from 2018 to 2021, six African countries reported human cases of Mpox with more than 18,000 suspected cases in the Democratic Republic of Congo alone [10]. Sporadic cases were also reported in the Western hemisphere in 2003, acquired from imported small mammals co-housed with prairie dogs. Barely recovering from an unprecedented COVID-19 pandemic, cases of Mpox spread outside the endemic regions, raising concerns about another disruptive pandemic. By the 30^th of January 2023, over 85,000 confirmed cases and 89 deaths were reported to the World Health Organization from 110 countries [11]. While most cases in the recent outbreak in non-endemic countries affected MSM, cases were also reported among children, young adults, the elderly, and women [12]. Two of the cases in the UK had a recent travel history to Nigeria while one was a health worker who managed one of the cases [13]. However, most cases had no links with endemic countries. To ensure coordinated global solidarity, the WHO declared the outbreak a public health emergency of international concern on the 23^rd of July 2022 [11]. The US followed suit by declaring Mpox a public health emergency on the 4^th of August 2022.

Nigeria is one of the Mpox endemic West African countries [14]. Historically, the largest outbreak in Nigeria occurred in 2017 with 197 suspected and 68 confirmed cases, and between September 2017 and June 2022, a total of 622 suspected cases of Mpox were reported from 33 states, including Kano-the most populous state in Nigeria [15]. This study aims to assess awareness, sources of information, risk perception, and correlates of Mpox vaccine acceptability among adults in metropolitan Kano.

Methods     

Study area and population: the study was conducted in two metropolitan local government areas (LGAs), Nasarawa and Tarauni in Kano, in northern Nigeria. The projected populations of Tarauni and Nasarawa LGAs were 971,043 and 360,261, respectively [16]. The main occupations of inhabitants are trading, entrepreneurship, civil service, and farming. The study population consisted of adult men and women (≥18 years) resident in Kano for at least 6 months. Visitors, persons who withheld consent, and those with cognitive impairment were excluded.

Study design and sampling: a mixed methods sequential, explanatory design was used with a pragmatic paradigm. The sample size was estimated using Fisher´s formula [17], Mpox acceptance from a previous study (50%) [18], 95% confidence level, and 5% error margin. The calculated minimum sample size (385) was increased by 10% to address non-response and rounded up to 450.

A multistage sampling method was used. In the first stage, half of the ten wards in each of the two LGAs were sampled using a simple ballot. In the second stage, one settlement was selected from each sampled ward using the same method. Numbers were then allotted to the selected settlements proportionate to their populations. After household enumeration and sampling interval determination, systematic sampling was used to select respondents in each settlement. The first household was selected by simple ballot between households whose serial number was 1 and the one whose serial number corresponds with the settlement´s sampling interval. Subsequent households were identified by adding the sampling interval to the previously studied household´s serial number. Finally, within each sampled household, eligible adults consented after a detailed explanation of the study objectives. When more than one eligible respondent was found in a household, only one selected by simple ballot was interviewed.

Measures and data collection: the survey questionnaire was adapted from previous studies [19,20]. The first section documented socio-demographic characteristics, including age, sex, marital status, ethnicity, education, religion, occupation, parity, history of a chronic medical disorder, and self-assessed health status. The second section inquired about awareness of Mpox, sources of information, messages received, perceived causes, sources of infection, species affected, transmission, and symptoms. The third section determined self-perceived Mpox risk using the question “How would you assess your chance of getting Mpox? The responses were ('high' or 'low'), whether or not the respondent was worried about getting Mpox, perceived severity, and whether the respondent knew someone who had Mpox. The fourth section determined Mpox vaccine acceptability by asking, 'If the Mpox vaccine is made available, will you take it? Response options include 'I will take it', 'I am not sure' and 'I will not take it'.

To determine the psychometric properties (re-validation, reliability, and consistency) of the adapted questionnaire, a pretest was carried out on a 10% sample of the questionnaires in another community (Gwale LGA, Kano, Nigeria). All scales were reliable and sections were consistent with Cronbach's alpha of at least 0.80. To elaborate on the survey responses, twenty survey respondents were purposively selected and interviewed in-depth. These semi-structured interviews explored motivations for vaccine acceptance and reasons for hesitancy or ambivalence. There were probes for nuanced descriptions. Sample stratification was based on profession and gender.

The study protocol was reviewed and approved by the Kano State Ministry of Health research ethics committee. Using the local Hausa language, trained research assistants informed eligible persons in sampled households about the study objectives, eligibility criteria, sampling process, and procedure. Participants were also informed that involvement was voluntary and that withholding consent had no consequences. Literate persons provided signed informed consent, while their non-literate counterparts thumb-printed the consent form before the interviews. Interviews were conducted face-to-face, in the respondents´ homes, away from other family members. Completed questionnaires were checked in the field by the supervisors and independently entered into a password-protected database by data clerks at Aminu Kano Teaching Hospital. Research staff received training on establishing rapport, obtaining informed consent, protecting human research participants, and conducting interviews.

Statistical analysis: data were analyzed using SPSS Version 27 (IBM Corp., Armonk, NY). Numeric variables were summarized using means, standard deviation, or median and range. Categorical variables were presented as frequencies and percentages. Pearson´s Chi-square or Fisher´s exact test was used to test the association between socio-demographic (respondent´s sex, ethnic group, religion, number of children, occupation, perceived severity of Mpox, Mpox risk perception, vaccines protect against diseases, have received a vaccine in adulthood, vaccinated against COVID-19) and the primary outcome, (willingness to be vaccinated against Mpox) [21]. Type I error was fixed at 5% for all tests. Binary logistic regression model was used to determine the independent predictors of willingness to be vaccinated against Mpox. A stepwise logistic regression model included independent variables with p<0.10 at the bivariate level [22]. Adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) were used to measure the strength and direction of the effect of the independent variables on the outcome. Hosmer-Lemeshow statistic and Omnibus tests were used to determine model fitness, with a Hosmer-Lemeshow chi-square yielding a p-value of >0.05 considered a good fit [23].

Qualitative data analysis: qualitative interviews were recorded and transcribed verbatim. Thematic analysis was performed based on the 'Framework Approach' [24], and included familiarization through repeated reading, coding, theme generation, applying the codes to the transcripts, matrix formation, and interpretation. Findings from the two components of the mixed-methods study were integrated [25].

Results     

Of the 450 people invited, (92.2%, n=415) completed the interviews. Most respondents were female (62.2%, n=258), of Hausa-Fulani ethnicity (91.6%, n=380) and Muslim (96.6%, n=401). Respondents´ mean age (± standard deviation (SD) was 31.9 ± 10.78 years, and the majority (88.7%, n=368) had at least secondary education. Over one-tenth (13.5%, n=56) had a chronic medical illness and one-fifth (21.0%, n=87) were vaccinated against COVID-19 (Table 1). The majority of respondents (94.9%, n=394) considered vaccines to be protective, and (43.9%, n=182) had received a vaccine as adults. Further, about half (51.6%, n=214) of the respondents had fully immunized or up-to-date children.

Awareness of Mpox, risk perceptions and sources of information: nearly all respondents (99.0%, n=411) have heard about Mpox, mainly on radio (89.6%), social media (40.2%), television (18.3%), and from healthcare workers (14.5%). Messages received include sources of infection (45.5%), mode of spread (47.2%), symptoms (53.3%), and prevention (29.9%). The majority of respondents indicated that Mpox was caused by a virus (60.7%, n=252), others mentioned bacteria (12.8%, n=53), and witchcraft/evil spirits (0.96%, n=4). Most respondents (81.0%, n=336) indicated that Mpox affects humans, with (15.2%, n=63) mentioning monkeys. Transmission methods mentioned include consumption of monkey/bush meat (48.2%), contact with infected animals (24.1%), and patients (17.6%). A few respondents (1.4%) considered the possibility of sexual transmission. Over one half of the respondents (52.8%) felt Mpox is a serious disease, 45.1% were worried, but only 3.6% self-assessed a high risk (Table 2).

Willingness to accept Mpox vaccination and reasons for hesitancy: half of the respondents (49.9%, n=207) were willing to take the Mpox vaccine, about one-third (37.6%, n=156) were undecided and the rest (12.5%, n=52) were unwilling. Of those that were unwilling or undecided (n=208), over one-half (55.8%, n=116) were concerned about vaccine safety, (19.7%, n=41) self-assessed a low risk, (15.9%, n=33) had little trust in the authorities and pharmaceutical companies, and (13.5%, n=28) did not consider Mpox a threat (Table 2).

Predictors of Mpox vaccine acceptability: bivariate analysis showed an association between Mpox vaccine acceptance and gender, ethnicity, religion, and occupation. In addition, vaccine acceptance was associated with perceived severity, risk perception, belief in the effectiveness of vaccines, vaccination during adulthood, and COVID-19 vaccination (p<0.05). At the multivariate level, the same factors independently predicted Mpox vaccine acceptance, except occupation. Specifically, female respondents were 33% less likely to accept Mpox vaccination (adjusted odds ratio, aOR = 0.67, 95% confidence interval CI: 0.42-0.92). In contrast, non-Hausa/Fulani respondents had 56% (aOR = 1.56, 95% CI, 1.10-3.85) increased likelihood of accepting the Mpox vaccine. Likewise, non-Muslim respondents had almost six-fold increased odds of vaccine acceptance (aOR = 5.70, 95% CI, 1.14-37.79). In addition, respondents who perceived Mpox as a severe disease (aOR = 1.37, 95% CI, 1.12-2.20) had 37% increased likelihood of vaccine acceptance, while a high self-assessed risk (aOR = 2.10, 95% CI, 1.10-7.46) doubled the odds of vaccine acceptance. Further, respondents who perceived vaccines as protective (aOR = 8.99, 95% CI, 1.79-45.30) and received vaccination during adulthood (aOR = 3.58, 95% CI, 2.20-5.82) had nine- and three-fold increased odds of accepting Mpox vaccine. Finally, respondents vaccinated against COVID-19 (aOR = 2.86, 95% CI, 1.45-5.64) had nearly three-fold increased probability of accepting Mpox vaccine (Table 3).

Qualitative findings: in-depth interview themes included perceptions about Mpox disease, transmission, the possibility of sexual transmission, high-risk groups, perceived severity, risk perception, precautions, willingness to take the vaccine, and reasons for vaccine hesitancy.

Perceptions of Mpox: participants considered Mpox a simulation of smallpox, and unlike smallpox, Mpox heals without scars. They also indicated that Mpox is a viral disease affecting mostly children, the elderly, those living in unhygienic environments, and those in occupations involving handling animals and bush meat. Others stated that Mpox is acquired from eating leftover fruits and drinking water from monkey-frequented ponds.

“I think Mpox is an imitation of smallpox (Hausa: Agana) and heals without scars. In contrast, smallpox leaves permanent scars on the face (Hausa: zanzana), making it easy to distinguish between the victims of the two diseases after recovery. Earlier we thought these diseases were caused by evil spirits, but the message we hear these days is that they are caused by germs,” man, 51-year-old.

“Mpox (Hausa: Farankaman birai) is caused by a virus that affects children, older people, and those engaged in occupations that involve close contact with animals (such as hunters, butchers and herdsmen). It is acquired through close contact with monkeys, eating or dealing in bush meat, and living in crowded unhygienic environments, particularly in rural areas,” woman, 43-year-old.

Transmission of Mpox: some participants indicated that Mpox is transmitted through close contact, body fluids, and sharing beddings and personal effects with patients, and through the respiratory route. Others mentioned eating leftover food and contaminated water while others entertained the possibility of a supernatural source.

“Mpox is transmitted by monkeys to humans when they (humans) drink water from ponds frequented by monkeys or when they eat fruits and other leftover food eaten by monkeys. Sharing beddings and clothes with a patient afflicted with Mpox, and sharing bathing sponges and soap can transmit the infection. It can also be gotten from breathing close to those affected and living in crowded rooms,” man, 30-year-old.

“First and foremost, all illnesses including Mpox are from God. In addition, when you eat fruits or food half eaten by monkeys, or you drink from the same ponds where sick monkeys drank, you can get Mpox. It is also caused by living in an untidy environment, eating bush meat, and partaking in bush meat from sick animals, including chicken,” woman, 26-year-old.

Sexual transmission: though participants indicated that Mpox was not one of the recognized sexually transmitted infections in the community, participants were of the view that sexual transmission could occur due to intimate body contact during such encounters.

“Yes, people are at risk of getting infected with Mpox sexually. For instance, because of financial difficulties and poverty, women involved in the commercial sex business come into intimate contact with many people. If any of these clients have Mpox, she will contract it and spread it to her new customers,” man, 30-year-old.

“I cannot say if Mpox can be transmitted through sex. It is not among the diseases we know that are sexually transmitted. The indisputable ones are gonorrhea, syphilis, and HIV. But I can imagine, since sexual contact involves intimacy, it is possible. Though I have not heard of any such cases in this community,” woman, 26-year-old.

Perceived severity: participants consider Mpox a serious disease and that it could be severe. Though compared to smallpox, Mpox was seen as milder. Nonetheless, participants advised that measures should be promptly taken to control the disease.

“Mpox is a serious health problem. It is contagious and can make people very sick, but it is not as deadly as smallpox. Health authorities should not handle it with levity as they initially did with COVID-19. It should be taken seriously before it gets out of hand,” woman, 35-year-old.

“Mpox can be severe and easily spreads like other infectious diseases. It is a serious health problem, like COVID-19, spreads easily and is a major concern in this community because people travel from other parts of this country for business,” man, 45-year-old.

Perceived high-risk groups: participants identified hunters, cattle herders, fishermen, animal handlers, and health workers as the most at-risk groups. Regarding age groups affected, children, and the elderly were considered more vulnerable because of immaturity and immunosenescence, respectively.

“People at high risk of Mpox include hunters, cattle herders, and fishermen. People who come in contact with animals such as veterinarians, butchers, zoo keepers, and farmers. Also, healthcare workers are at risk of getting infected by their patients,” woman, 28-year-old.

“Children, young people, HIV and diabetic patients, and the elderly are at high risk of contracting Mpox. The elderly, because of their frailty, diminishing immunity, interaction with different kinds of people, and healthcare workers. Also, villagers who eat leftover mangoes eaten by monkeys without washing them can get infected,” woman, 38-year-old.

Risk perception: some participants justified their low-risk perception since they are not hunters, butchers, or bushmeat traders. In contrast, those engaged in these trades self-assessed their risk of acquiring Mpox high.

“No, I am not at risk of getting infected with Mpox, because I don´t have any relationship with animal hunters nor do I eat or engage in the bush meat trade,” man, 42-year-old.

“Yes, of course, I am at risk of Mpox because I interact with so many people, and being a butcher, my job entails handling animals, slaughtering them, and selling bush meat. Who knows, some of the animals could be infected and transmit the disease to me. God help us,” man, 39-year-old.

Encounters with affected persons: a participant narrated his encounter with a suspected case of Mpox during a business trip to the central parts of Nigeria. Another participant recounted his experience with a suspected case two years earlier.

“I encountered a likely case of Mpox in Ude village in Benue State during a business trip. In that community, roasted bush meat is a popular delicacy usually accompanied by a local alcoholic brew. In the market, I came across a person who had rashes all over his body and people avoided him. Some practically ran away from him and I also joined them for my safety. When I enquired about the man´s disease, they told me, it was Mpox and that the man was a hunter who also engages in the preparation and sale of monkey meat,” man, 42-year-old.

“Yes, I came across a person infected with Mpox in our community, about two years ago. He had rashes all over his body. He is now completely healed. The rashes disappeared without scars unlike those of smallpox patients years ago,” man, 31-year-old.

Precautions against Mpox: participants indicated that they avoided persons with suspected lesions and those whose occupation involves handling animals. They also avoided bush meat and used face masks in crowded places.

“One of the precautionary measures I take is not to come in close contact with a person with skin eruptions, and people whose jobs entail hunting, handling animals, including monkeys, and I do not go to places where bush meat is sold. I always wear a face mask in public places,” man, 42-year-old.

“To avoid Mpox, I distance myself from persons suspected to have Mpox. Secondly, I used to maintain a clean environment, wash my hands regularly, use a facemask, avoid sickly pets and animals, eat a well-balanced diet, and drink clean water,” man, 39-year-old.

Willingness to take Mpox vaccine: some participants were willing to take the vaccine unperturbed by rumors regarding the safety or side effects. They would also encourage their family to take the vaccine as they did during the COVID-19 pandemic.

“Yes, I am willing, like I told you, if the vaccine is available now, I would be the first person to take it to protect myself and my family from getting Mpox. When the COVID-19 vaccine came, I and my family were among the first to take the vaccine regardless of the baseless rumors and we have been vindicated,” man, 39-year-old.

“I am ready and willing to be vaccinated against Mpox disease, with all my family members. I know it will prevent us from getting infected with Mpox. We are not disturbed by the stories and rumors being peddled about vaccines. We have confidence in the health workers and they mean well,” man, 31-year-old.

Reasons for vaccine hesitancy

Some participants were unwilling to take the Mpox vaccine for a variety of reasons. These include the newness of the vaccine, inadequate information safety, hesitancy among some health workers, and the hurried introduction of new vaccines compared to the older well-tested ones. Others were afraid of side effects and related it to the experience with COVID-19 vaccines and rumors of deaths on social media.

“You know this Mpox vaccine you are talking about is new to us. We are not well-informed about it. Though many of us trust healthcare workers, even the HCWs appear not to be convinced as some of them even reject polio vaccines. they are unable to give us sufficient information about the safety of the vaccine. So, this is the problem. We do not want this hurried production of new vaccines. We trust older vaccines like the smallpox vaccine, measles, and BCG which have been in use for a long time,” man, 39-year-old.

“We are afraid of the side effects of the vaccine. For instance, when some people took the COVID-19 vaccine, they had a fever and couldn´t use their hands for some days. There are also reports of deaths on social media. Though we believe that healthcare workers will not deliberately harm us. However, we are scared of the unknown effects of the new vaccines, which the HCWs also do not seem to know. So, we want them (HCWs) to take the vaccine first. If nothing happens to them, then we will take it,” man, 45-year-old.

Other participants were unwilling to take the Mpox vaccine (which they perceive authorities are interested in) in protest against their poor economic situation, hunger, poverty, and perceived neglect of the real problems bedeviling their society in preference for some foreign agenda. They also indicated that Mpox cases are few and therefore not a priority.

“I am not ready to take any Mpox vaccine because we have no food and no medicines for real diseases like malaria, cough, and other illnesses. Instead of solving these problems, the health authorities and government focus on an imaginary disease (Mpox) that most of the members of the community have not seen or even heard about,” woman, 42-year-old.

“I am not interested in taking the Mpox vaccine because it is all global politics. If not, why not provide free food, and antimalarials, our genuine needs, instead, they are spending our money on a vaccine for a disease that many people are not even aware of. It is not our problem, for now, let´s concentrate on our immediate challenges,” man, 47-year-old.

Some participants view the emphasis on vaccines for diseases such as Mpox as a foreign agenda and a means of maximizing profits for western pharmaceutical companies and their collaborators in government, as they wondered why their pressing needs were ignored for some imagined health threat. Further, some participants perceived the new vaccines as a ploy for controlling the population in Muslim nations.

“New vaccines are produced mainly for the profiteering of western pharmaceutical companies and their local collaborators. Let them distribute the money used to buy the vaccines to alleviate poverty and solve our pressing needs. We also sense some foreign agenda to curb the increasing Muslim population” man, 30-year-old.

Participants also referred to conflicting messages on social media regarding the dangers associated with new vaccines, which erode their confidence in these vaccines. Concerns were expressed about the complex technology deployed for vaccine production without ascertaining the long-term effects.

“I am not willing to take the Mpox vaccine just yet, as there have been rumors on social media about new vaccines since the COVID-19 outbreak. The conflicting messages make it difficult for us to trust the products. The complicated technology used and uncertainty about their long-term safety is my major worry,” man, 45-year-old.

Some participants opined that since they are not involved with monkeys and other sources of bush meat, Mpox is not their problem. They suggested that the Mpox vaccine should be administered to those who consume bush meat and deal with monkeys in the southern parts of Nigeria.

“Mpox affects those that eat or sell bush meat. We do not eat bushmeat here nor are we involved in the trade. So, the vaccines should be given to those in other parts of Nigeria that eat monkey meat and deal in bush meat. That´s it,” man, 42-year-old.

Discussion     

We assessed public awareness, perceptions, and predictors of Mpox vaccine acceptability in Kano metropolis, in northern Nigeria. We found near-universal awareness of Mpox, mainly from electronic media (radio, social media, and television) delivering messages on sources, transmission, symptoms, and prevention. However, there were knowledge gaps, misconceptions, and low-risk perceptions. About one-half of respondents were willing to accept the vaccine and this was predicted by socio-demographic (gender, ethnicity, religion), susceptibility disease-related (perceived severity, risk perception), vaccine confidence (vaccines effectiveness), and health-related behavior (adulthood vaccination, and COVID-19 vaccination). Concerns about vaccine safety, rumors, low-risk perception, mistrust in authorities and pharmaceutical companies, and low-felt need fueled vaccine hesitancy.

The high public awareness about Mpox mostly from electronic media sources is similar to reports from south-south Nigeria [26], where over one half (55%) of the respondents mentioned radio/television as sources followed by HCWs (30.8%) [26]. Similarly, study participants in Nigeria cited government as their source of information [27], while the US public cited online resources and trusted health professionals [28]. Nonetheless, there were misconceptions about the causative agent, and transmission, echoing findings from the US [28], Malaysia [29], and China [30]. The routes of transmission of the Mpox virus include direct and indirect contact with an infected animal, human secretions or lesions, or contaminated materials, informing the recommendation for self-isolation for 3 weeks [31,32]. The increasing role of social and traditional electronic media and the recent experiences with COVID-19 could explain the heightened public consciousness about diseases with epidemic potential. These channels could be prioritized when addressing knowledge gaps, myths, and misinformation.

The proportion of respondents who considered Mpox a serious threat (52.8%) was lower than in Saudi Arabia (63.3%) [33], but higher than in the US (26.4%) [28], and China (62.7%) [32]. However, the proportion of respondents who self-assessed a high risk (3.6%) was much lower than in Saudi Arabia (43.7%) [33], and China (62.7%) [30]. Similarly, the mention of hunters, butchers, and bushmeat dealers as occupational risk groups concurs with reports from parts of Nigeria and Africa [4]. For instance, in the DRC, members of the public identified contact with infected wildlife, peri-domestic animal bite, hunting, forest visits as Mpox risk behaviors. These risk groups should be prioritized for behavioral change communication, including vaccination and the adoption of alternative means of livelihood [4].

Mpox vaccine acceptance in our sample (49.9%) was comparable to reports from Ghana (46.1%) [34], Saudi Arabia (43.7%) [33], and the US (46%) [28], but lower than China (68.8%) [30]. Our figure was also comparable with the global average (43%), and the regional figure for Asia (50%), but lower than that of Europe (70%) [18], the global averages for healthcare workers (63.0%), and the LGBTI community (84.0%) [18]. Apart from variations in study timing, population, and methods, differences in disease burden, knowledge, risk perception, trust in authorities, and perceived benefits of Mpox vaccination could explain the disparity in vaccine acceptance. These modulators could inform strategies for enhancing vaccine uptake through appropriate risk communication and public engagement.

The reasons for Mpox vaccine hesitancy fit into four of the categories of the 5C model, including vaccine confidence (doubts about vaccine effectiveness, safety, and policymakers´ motivation), complacency (perceived risk and threat level), the risk-benefit calculation (information on benefits and effects of anti-vaccination campaigns, rumors) and vaccination being a collective community responsibility (willingness to protect others by getting vaccinated). The last category is illustrated by participants´ suggestions that vaccination be limited to more endemic settings and high-risk occupations [35]. Constraints to vaccination which constitute the last 'C' could surface after the rollout of the Mpox vaccination program. Our findings are similar to reports from other parts of Nigeria [26,36], Asia [30]. Europe and the United States [18,28]. Apart from study methods, motivations for vaccination could be influenced by philosophical stance, and community adhesion. In addition to the lingering effects of the COVID-19 anti-vaccination messages on public psyche, vaccination fatigue, low felt need, and perceived neglect of public priorities could underlie some of the resistance towards vaccination. Evidence-based steps are essential to counter misinformation, rebuild public trust, and vaccine confidence.

The predictive role of gender was also reported in Ghana [37], and could operate through rumors linking vaccines to infertility, and doubts about maternal and fetal safety during pregnancy and breastfeeding [38]. The influence of ethnicity could be related to the long-held belief that vaccination is a ploy for targeted population control and mistrust about the motives of authorities and pharmaceutical companies. Most religions encourage vaccination for protection against diseases. However, some religious leaders constitute obstacles, as was the case with polio vaccination campaigns in northern Nigeria [39]. Similarly, perceived disease severity and risk perception have been reported to influence health behavior including vaccination decisions [28,30]. Vaccination during adulthood, including COVID-19 vaccination [37], are indicators of a positive disposition towards vaccination [28,30].

Customized behavioral change communication interventions are necessary to address misconceptions and the low-risk perception. Before considerations for the rollout of the Mpox vaccination in Nigeria, appropriate risk communication and strategies to address the root causes of vaccine hesitancy should be implemented. This should include rumor surveillance, and counter-messaging to build public confidence. Appropriate messages should be conveyed through traditional and social media [27,28], with consideration for gender and socio-cultural peculiarities.

This mixed methods study is among the first to assess the acceptability of the Mpox vaccine in an endemic setting in northern Nigeria. The face-to-face survey ensured the inclusion of less tech-savvy individuals, while the in-depth interviews provided detailed descriptions of motives for vaccine acceptance and reasons for hesitancy in participants´ voices. Nonetheless, there is a need for caution when generalizing the findings given the cultural variations that exist across Nigeria. Future studies should assess the situation in other locations including rural and semi-urban settings.

Conclusion     

We found near-universal awareness of the Mpox vaccine coupled with misconceptions and low-risk perception of Mpox acquisition among respondents. Vaccine acceptance was sub-optimal and influenced by sociodemographic, vulnerability, and health behavior-related factors. Risk communication, strategic community engagement, and socio-behavioral interventions will help to address misconceptions, safety concerns, and vaccine hesitancy, and thereby increase vaccine uptake in similar settings.

Competing interests     

The authors declare no competing interests.

Funding     

This work is supported by the Fogarty International Center (FIC) and the National Institute on Alcohol Abuse and Alcoholism of the U.S. National Institutes of Health (NIH) (award number 1D43 TW011544) The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIDDK, NIH, the Department of Health and Human Services, or the government of the United States of America.

Authors' contributions     

Zubairu Iliyasu, Hadiza Musa Abdullahi, Fatimah Ismail Tsiga-Ahmed, Taiwo Gboluwaga Amole, Aminatu Ayaba Kwaku, and Tahir Dahiru conceived and designed the study. Zubairu Iliyasu, Hadiza Musa Abdullahi, Fatimah Ismail Tsiga-Ahmed, Aminatu Ayaba Kwaku, and Abubakar Mohammed Jibo performed the data collection. Zubairu Iliyasu, Fatimah Ismail Tsiga-Ahmed, Taiwo Gboluwaga Amole, and Aminatu Ayaba Kwaku conducted the statistical analysis. TD supervised the qualitative interviews. Zubairu Iliyasu, Fatimah Ismail Tsiga-Ahmed, Taiwo Gboluwaga Amole, Humayra Aisha Bashir, Hamisu Muhammed Salihu, and Muktar Hassan Aliyu drafted the manuscript. All authors contributed to the article, read and approved its final version.

Tables     

Table 1: sociodemographic characteristics of adult respondents, Kano, Nigeria, 2022

Table 2: monkeypox awareness, risk perception and vaccine acceptability, Kano, Nigeria (N=415)

Table 3: logistic regression model for predictors of monkeypox vaccine acceptability among adults, Kano, Nigeria (N=415)

References