Side Effects Reported by Jordanian Healthcare Workers Who Received COVID-19 Vaccines

Article

Side Effects Reported by Jordanian Healthcare Workers Who

Received COVID-19 Vaccines

Osama Abu-Hammad

1,2

, Hamza Alduraidi

, Shaden Abu-Hammad

, Ahmed Alnazzawi

, Hamzah Babkair

Abdalla Abu-Hammad

, Ibrahim Nourwali

, Farah Qasem

and Najla Dar-Odeh

1,2,



 

Citation: Abu-Hammad, O.;

Alduraidi, H.; Abu-Hammad, S.;

Alnazzawi, A.; Babkair, H.;

Abu-Hammad, A.; Nourwali, I.;

Qasem, F.; Dar-Odeh, N. Side Effects

Reported by Jordanian Healthcare

Workers Who Received COVID-19

Vaccines. Vaccines 2021, 9, 577.

https://doi.org/10.3390/

vaccines9060577

Academic Editors:

Luis Martinez-Sobrido and

Stefano D’Errico

Received: 23 April 2021

Accepted: 22 May 2021

Published: 1 June 2021

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This article is an open access article

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4.0/).

College of Dentistry, Taibah University, Al Madinah Al Munawara 43353, Saudi Arabia;

[email protected] (O.A.-H.); [email protected] (A.A.); [email protected] (H.B.);

[email protected] (I.N.)

School of Dentistry, University of Jordan, Amman 11942, Jordan

School of Nursing, University of Jordan, Amman 11942, Jordan; [email protected]

Comprehensive Amman Healthcare Center, Amman 11192, Jordan; [email protected]

School of Medicine, University of Jordan, Amman 11942, Jordan; [email protected]

University of Jordan Hospital, Amman 11942, Jordan; [email protected]

* Correspondence: [email protected]

Abstract:

Background Distribution of COVID-19 vaccines has been surrounded by suspicions and

rumors making it necessary to provide the public with accurate reports from trustworthy experts such

as healthcare professionals. Methods We distributed a questionnaire in Jordan among physicians,

dentists and nurses who received a COVID-19 vaccine to explore the side effects (SE) they encountered

after the ﬁrst or the second dose of one of three vaccines namely: AstraZeneca Vaxzevria (AZ), Pﬁzer-

BioNTeck (PB), and SinoPharm (SP) vaccines. Results A total of 409 professionals participated.

Approximately 18% and 31% of participants reported no SE after the ﬁrst dose and second dose,

respectively. The remainder had mostly local side effects related to injection site (74%). Systemic

side effects in the form of fatigue (52%), myalgia (44%), headache (42%), and fever (35%) prevailed

mainly after the ﬁrst dose. These were signiﬁcantly associated with AZ vaccine, and age

≤

45 years

(p = 0.000

and 0.01, respectively). No serious SE were reported. Conclusions We can conclude that SE

of COVID-19 vaccines distributed in Jordan are within the common range known so far for these

vaccines. Further studies are needed to include larger sample size and longer follow-up period to

monitor possible serious and long-term SE of the vaccines.

Keywords:

COVID-19; AstraZeneca vaccine; Pﬁzer-Bionteck vaccine; SinoPharm; side effects; health-

care professionals; physicians; nurses; dentists

1. Introduction

The long-awaited vaccines of COVID-19 (corona virus disease-2019) were not received

by cheers in many areas of the world whether in developed or developing countries where

a substantial proportion of populations cast their doubts and suspicions [

]. Many rumors

and misinterpretations surrounded the different vaccines to variable degrees.

The devastating pandemic caused by severe acute respiratory syndrome coronavirus

2 (SARS-CoV-2) has been associated with large numbers of cases, mortalities and severe

long-term complications inﬂuencing individuals and economies.

In Jordan, the ﬁrst cases of COVID-19 appeared in March 2020, but due to strict mea-

sures adopted by the government, the ﬁrst wave was mild, and outcomes of the pandemic

were relatively trivial [

]. However, the country was hit hard by a more aggressive second

wave during September 2020. As of mid-April 2021, the 10-million population country

had over 672,000 total cases (65,364 cases per million) and 7937 deaths (772 per million) [

Jordan was among the countries that had an early start in vaccination campaigns which

started in January 2021. Taking into consideration that older adults (aged

≥

70 years) are

Vaccines 2021, 9, 577. https://doi.org/10.3390/vaccines9060577 https://www.mdpi.com/journal/vaccines

Vaccines 2021, 9, 577 2 of 10

at increased risk of severe disease and death if they develop COVID-19 [

], these were

prioritized for vaccination. Healthcare workers were also selected for vaccination according

to their age, hence, there were several COVID-19 related deaths registered among them.

Although many physicians were reported dead due to infection, the nation was

shocked to receive the news of a young female physician who contracted infection and

later was deceased due to the infection in late March 2021. Consequently, the Jordanian

government intensiﬁed the vaccination campaigns and initiated a campaign that speciﬁcally

targets all healthcare workers regardless their age. A nationwide campaign was established

by the Ministry of Health and under a close supervision by armed forces to provide vaccines

free of charge to all healthcare personnel.

Three types of vaccines are being administered currently in Jordan according to

availability: AstraZeneca Vaxzevria, Pﬁzer-BioNTeck (PB), and SinoPharm (SP) vaccines.

SE to COVID-19 vaccines were, and still are, a controversial issue and a continuously

evolving situation. According to Centers of Disease Control and Prevention (CDC), the

common adverse effects include pain, swelling and redness at injection site, as well as

fatigue, chills, fever, myalgia, headache, and nausea [5].

The vaccination campaign in Jordan was counteracted by another campaign spreading

doubts around the efﬁcacy of these vaccines and intensifying fears around their safety

proﬁle. Despite the large numbers of COVID-19 cases and the early start of the vaccination

campaign in Jordan, there is little data on either clinical outcomes of infection or even the

SE of vaccines. It is important at this stage to collect data on these SE of distributed vaccines

so as to inform and educate the public on this issue. More importantly, it is essential to

collect this data from trustworthy and expert sources who are willing to provide accurate

and transparent data that is not affected by geopolitical vaccine wars.

Therefore, we invited Jordanian healthcare professionals including physicians, nurses

and dentists to report the SE they encountered after receiving one or two doses of COVID-19

vaccines.

2. Materials and Methods

This was a cross-sectional survey utilizing an online questionnaire. The questionnaire

was anonymous, and it was composed of eight closed-ended questions on gender, age,

occupation, vaccine type, observed side effects and their duration after ﬁrst dose and

second dose. The questionnaire was distributed among three categories of healthcare

personnel in Jordan: nurses, dentists and physicians.

The study was ethically approved by the ethical committee, School of Nursing, Uni-

versity of Jordan IRB#PF.21.14.

Statistical Analysis

IBM-SPSS statistical package for social sciences version 21 (IBM Corp: Armonk,

NY, USA) was used to obtain descriptive statistics and signiﬁcant associations between

variables.

Descriptive statistics were reported as frequencies and percentages, means and stan-

dard deviations. Cross tabulation with chi square test was carried out to identify signiﬁcant

associations between severity of side effects as the dependent variable and independent

variables of vaccine type, gender and age.

3. Results

The study sample consisted of 409 healthcare personnel (nurses, dentists or doctors)

working in Jordan.

3.1. Participants’ Characteristics

Age, gender distribution, profession, and vaccine types received are displayed in

Table 1.

Vaccines 2021, 9, 577 3 of 10

Table 1. Study sample sociodemographics (N = 409) and types of administered vaccines.

Variable

Dose 1 Recipients

Total (409)

Dose 2 Recipients

Total (195)

Age (years) (Mean ± SD) 34.99 ± 12.07 39.27 ± 12.79

Number (%) Number (%)

Gender

Male 120 (29.3%) 67 (34.4%)

Female 289 (70.7%) 128 (65.6%)

Profession

Physician 144 (35.2%) 71 (36.4%)

Dentist 172 (42.1%) 70 (35.9%)

Nurse 93 (22.7%) 54 (27.7%)

Vaccine type

AZ 179 (43.8%) 7 (3.6%)

PB 141 (34.5%) 101 (51.8%)

SP 89 (21.8%) 87 (44.6%)

AZ: AstraZeneca Vaxezevira; PB: Pﬁzer BioNTech vaccine, SP: SinoPharm vaccine.

3.2. Reported Side Effects

Number of side effects reported after receiving the ﬁrst dose ranged between 0 and

11 for each participant, with a mean of 3.2

2.7 per participant. Number of side effects

reported after receiving second dose ranged between 0 and 9, with a mean of 1.4

2 per

participant. Figure 1 presents the reported SE of each vaccine listed according to their

frequency and Tables 2 and 3 present frequency (%) of side effects reported after ﬁrst and

second doses, and statistical signiﬁcance of their association with various vaccine types

after the ﬁrst dose and second dose separately.

Vaccines 2021, 9, x FOR PEER REVIEW 3 of 11

3.1. Participants’ characteristics

Age, gender distribution, profession, and vaccine types received are displayed in Ta-

ble 1.

Table 1. Study sample sociodemographics (N = 409) and types of administered vaccines.

Variable

Dose 1 Recipients

Total (409)

Dose 2 Recipients

Total (195)

Age (years) (Mean ± SD)

34.99 ± 12.07

39.27 ± 12.79

Number (%)

Gender

Male

120 (29.3%)

67 (34.4%)

Female

289 (70.7%)

128 (65.6%)

Profession

Physician

144 (35.2%)

71 (36.4%)

Dentist

172 (42.1%)

70 (35.9%)

Nurse

93 (22.7%)

54 (27.7%)

Vaccine type

179 (43.8%)

7 (3.6%)

141 (34.5%)

101 (51.8%)

89 (21.8%)

87 (44.6%)

AZ: AstraZeneca Vaxezevira; PB: Pfizer BioNTech vaccine, SP: SinoPharm vaccine.

3.2. Reported Side Effects

Number of side effects reported after receiving the first dose ranged between 0 and

11 for each participant, with a mean of 3.2 ± 2.7 per participant. Number of side effects

reported after receiving second dose ranged between 0 and 9, with a mean of 1.4 ± 2 per

participant. Figure 1 presents the reported SE of each vaccine listed according to their

frequency and Tables 2 and 3 present frequency (%) of side effects reported after first and

second doses, and statistical significance of their association with various vaccine types

after the first dose and second dose separately.

Figure 1. Reported side effects of vaccines arranged according to their frequency. AZ: AstraZeneca

Vaxezevira; PB: Pfizer BioNTech vaccine, SP: SinoPharm vaccine.

Figure 1.

Reported side effects of vaccines arranged according to their frequency. AZ: AstraZeneca

Vaxezevira; PB: Pﬁzer BioNTech vaccine, SP: SinoPharm vaccine.

Vaccines 2021, 9, 577 4 of 10

Table 2.

Side effects (number/percentage) occurring after each vaccine, and statistical signiﬁcance of their association with

various vaccine types after dose 1 (number = 409).

Side Effects

Vaccine Type

Total

Number (%)

p-Value

Number (%)

SP-PB SP-AZ PB-AZ

Side effects

No side effects

41 (46.1%)

48 (53.9%)

118 (83.7%)

23 (16.3%)

175 (97.8%)

4 (2.2%) 75 (18.3%)

0.000 0.000 0.000

Fever

Yes

81 (91.0%)

8 (9.0%)

132 (93.6%)

9 (6.4%)

47 (26.3%)

132 (73.7%) 149 (36.4%)

0.462 0.000 0.000

Fatigue

Yes

75 (84.3%)

14 (15.7%)

96 (68.1%)

45 (31.9%)

27 (15.1%)

152 (84.9%) 211 (51.6%)

0.006 0.000 0.000

Myalgia

Yes

83 (93.3%)

6 (6.7%)

111 (78.7%)

30 (21.3%)

36 (20.1%)

143 (79.9%) 179 (43.8%)

0.003 0.000 0.000

Bone pain

Yes

89 (100.0%)

0 (0.0%)

131 (92.9%)

10 (7.1%)

100 (55.9%)

79 (44.1%) 89 (21.8%)

0.010 0.000 0.000

Joint pain

Yes

87 (97.8%)

2 (2.2%)

122 (86.5%)

19 (13.5%)

77 (43.0%)

102 (57.0%) 123 (30.1%)

0.004 0.000 0.000

Headache

Yes

78 (87.6%)

11 (12.4%)

102 (72.3%)

39 (27.7%)

56 (31.3%)

123 (68.7%) 173 (42.3%)

0.006 0.000 0.000

Injection site pain

Yes

57 (64.0%)

32 (36.0%)

34 (24.1%)

107 (75.9%)

16 (8.9%)

163 (91.1%) 302 (73.8%)

0.000 0.000 0.000

Arm numbness

Yes

86 (96.6%)

3 (3.4%)

124 (87.9%)

17 (12.1%)

138 (77.1%)

41 (22.9%) 61 (14.9%)

0.023 0.000 0.012

Diarrhea

Yes

89 (100.0%)

0 (0.0%)

139 (98.6%)

2 (1.4%)

162 (90.5%)

17 (9.5%) 19 (4.6%)

0.259 0.003 0.002

Shortness of breath

Yes

89 (100.0%)

0 (0.0%)

139 (98.6%)

2 (1.4%)

162 (90.5%)

17 (9.5%) 19 (4.6%)

0.259 0.003 0.002

Dizziness

Yes

88 (98.9%)

1 (1.1%)

141 (100.0%)

0 (0.0%)

173 (96.6%)

6 (3.4%) 7 (1.7%)

0.207 0.281 0.028

Vomiting

Yes

89 (100.0%)

0 (0.0%)

141 (100.0%)

0 (0.0%)

173 (96.6%)

6 (3.4%) 6 (1.5%)

vomit-

ing

0.081 0.028

Nausea

Yes

89 (100.0%)

0 (0.0%)

141 (100.0%)

0 (0.0%)

168 (93.9%)

11 (6.1%) 11 (2.7%)

nausea

0.017 0.003

Ear symptoms

Yes

88 (98.9%)

1 (1.1%)

140 (99.3%)

1 (0.7%)

177 (98.9%)

2 (1.1%) 4 (1%)

0.742 0.996 0.707

Sore throat

Yes

89 (100.0%)

0 (0.0%)

140 (99.3%)

1 (0.7%)

178 (99.4%)

1 (0.6%) 2 (0.5%)

0.426 0.480 0.865

AZ: AstraZeneca Vaxezevira; PB: Pﬁzer BioNTech vaccine, SP: SinoPharm vaccine.

Vaccines 2021, 9, 577 5 of 10

Table 3.

Side effects (number/percentage) occurring after each vaccine, and statistical signiﬁcance of their association with

various vaccine types after dose 2 (number = 195).

Side Effects Dose 2

VACCINE TYPE

Total

Number (%)

p-Values

Number (%)

SP-PB SP-AZ PB-AZ

Side effects present

No side effects

47 (52.8%)

42 (47.2%)

125 (88.7%)

16 (11.3%)

176 (98.3%)

3 (1.7%) 61 (31.3%)

0.000 0.000 0.000

Headache

Yes

78 (87.6%)

11 (12.4%)

104 (73.8%)

37 (26.2%)

177 (98.9%)

2 (1.1%) 50 (25.6%)

0.012 0.000 0.000

Fever

Yes

85 (95.5%)

4 (4.5%)

110 (78.0%)

31 (22.0%)

176 (98.3%)

3 (1.7%) 38 (19.5%)

0.000 0.173 0.000

Fatigue

Yes

74 (83.1%)

15 (16.9%)

82 (58.2%)

59 (41.8%)

178 (99.4%)

1 (0.6%) 75 (38.5%)

0.000 0.000 0.000

Myalgia

Yes

76 (85.4%)

13 (14.6%)

104 (73.8%)

37 (26.2%)

178 (99.4%)

1 (0.6%) 51 (26.2%)

0.037 0.000 0.000

Injection site pain

yes

56 (62.9%)

33 (37.1%)

66 (46.8%)

75 (53.2%)

175 (97.8%)

4 (2.2%) 112 (57.4%)

0.017 0.000 0.000

Numbness injection

site

Yes

84 (94.4%)

5 (5.6%)

132 (93.6%)

9 (6.4%)

178 (99.4%)

1 (0.6%) 15 (7.7%)

0.813 0.008 0.003

Joint pain

Yes

86 (96.6%)

3 (3.4%)

118 (83.7%)

23 (16.3%)

178 (99.4%)

1 (0.6%) 27 (13.8%)

0.003 0.074 0.000

Diarrhea

Yes

88 (98.9%)

1 (1.1%)

137 (97.2%)

4 (2.8%)

178 (99.4%)

1 (0.6%) 6 (3.1%)

0.386 0.613 0.103

Shortness of breath

Yes

87 (97.8%)

2 (2.2%)

133 (94.3%)

8 (5.7%)

179 (100.0%)

0 (0.0%) 10 (5.1%)

0.215 0.044 0.001

Bone pain

Yes

85 (95.5%)

4 (4.5%)

122 (86.5%)

19 (13.5%)

177 (98.9%)

2 (1.1%) 25 (12.8%)

0.027 0.078 0.000

Three participants had COVID-19 infection after the ﬁrst dose of PB vaccine and two had the infection after the AZ vaccine, however, the p

value was insigniﬁcant (p = 0.354). Additionally, two had the infection after the second dose of the SP vaccine and one after the PB vaccine,

however, the p value was not signiﬁcant (p = 0.127). AZ: AstraZeneca Vaxezevira; PB: Pﬁzer BioNTech vaccine, SP: SinoPharm vaccine.

Table 4 presents less frequent side effects that occurred after ﬁrst or second dose for

all vaccines.

3.3. Relationship of Severity of Side Effects with Age and Gender and Vaccine Type

Severity was expressed as no reported side effects, local side effects (injection site pain

or arm numbness) and systemic side effects (all remaining side effects). Cross tabulation

of severity of side effects with type of vaccine following both doses, showed that AZ was

found to be signiﬁcantly associated with more severe side effects, while SP was signiﬁcantly

associated with no side effects and PB was signiﬁcantly associated with local side effects

(p = 0.000) (Table 5). Age group but not gender was signiﬁcantly associated with severity

of SE after ﬁrst dose only (p = 0.01), however, no statistically signiﬁcant association was

found between either gender or age group and severity of SE after second dose (p > 0.05).

Vaccines 2021, 9, 577 6 of 10

Table 4. Frequency (%) of less frequent side effects after dose 1 and dose 2 of various vaccines.

Side Effect

Vaccine Type

Total

N = 409

SP (N = 89)

N (%)

PB (N = 141)

N (%)

AZ (N = 179)

N (%)

First dose

Chest pain 0 0 1 (0.6%) 1 (0.2%)

Common cold 1 (1.1%) 0 0 1 (0.2%)

Cough 0 0 1 (0.6%) 1 (0.2%)

Herpes zoster 0 1 (0.7%) 0 1 (0.2%)

Loss of smell 0 1 (0.7%) 0 1 (0.2%)

Lower back pain 0 0 1 (0.6%) 1 (0.2%)

Palpitations 0 0 1 (0.6%) 1 (0.2%)

Redness and swelling (injection site) 0 1 (0.7%) 0 1 (0.2%)

Sleepiness 1 (1.1%) 0 0 1 (0.2%)

Thirst 0 0 1 (0.6%) 1 (0.2%)

Urticaria 0 0 1 (0.6%) 1 (0.2%)

Burning pain in head 0 1 (0.7%) 0 1 (0.2%)

Loin pain 0 0 1 1 (0.2%)

Second dose

Cough 1 (1.1%) 0 0 1 (0.2%)

Diuresis 0 2 (1.4%) 0 2 (0.5)

Herpes zoster 1 (1.1%) 0 0 1 (0.2%)

Sleepiness 1 (1.1%) 0 0 1 (0.2%)

Table 5. Cross tabulation of severity of side effects after doses 1 and 2 with age groups, gender and vaccine type.

Severity of Side Effects after Dose 1 No Side Effects Local Systemic p-Value

Age (years)

≤45

>45

45 (15.8%)

2 (30.3%)

70 (24.6%)

19 (21.3%)

170 (59.6%)

43 (48.3%) 0.010

Gender

Male

Female

23 (22.1%)

49 (18.1%)

3 (28.8%)

59 (21.9%)

51 (49.0%)

162 (60.0%)

0.154

Vaccine type

48 (60.0%)

21 (16.4%)

3 (1.8%)

20 (25.0%)

59 (46.1%)

10 (6.0%)

12 (15.0%)

48 (37.5%)

153 (92.2%)

0.000

Severity of side effects after dose 2

Age (years)

≤45

>45

37 (28.9%)

24 (35.8%)

20 (15.6%)

14 (20.9%)

71 (55.5%)

29 (43.3%)

0.266

Gender

Male

Female

22 (32.8%)

39 (30.5%)

8 (11.9%)

26 (20.3%)

37 (55.2%)

63 (49.2%)

0.340

Vaccine type

42 (48.3%)

16 (15.8%)

3 (42.9%)

19 (21.8%)

15 (14.9%)

0 (0.0%)

26 (29.9%)

70 (69.3%)

4 (57.1%) 0.000

AZ: AstraZeneca Vaxezevira; PB: Pﬁzer BioNTech vaccine, SP: SinoPharm vaccine.

3.4. Duration of Systemic Side Effects after Dose 1 in Days

On average systemic side effects lasted for 1.39

1.12 days, with a range of 0–5 days.

When the patient reported recovery from severe SE within 24 h of their start, the duration

was calculated as 0 days.

4. Discussion

We conducted this study to explore the side effects of COVID-19 vaccines among their

recipients of healthcare professionals to ensure, as much as possible, the accuracy and

credibility of data collected. Physicians, nurses, and dentists were invited to participate

Vaccines 2021, 9, 577 7 of 10

in this survey because we think that these professionals are strongly related to the critical

health aspects of the pandemic. Physicians and nurses work in the front lines in the combat

against the pandemic, whereas dentists are at a high risk to contract the infection due to

the intimate and risky nature of dental practice in dealing with highly infectious ﬂuids and

aerosols [6].

Until now vaccination campaigns against COVID-19 have been inﬂuenced by rumors,

suspicions, hesitancy and refusal. There was also exaggeration and over-reporting of

adverse effects of vaccines, as some of these effects are normal physiologic processes or

developmental anomalies that cannot be related in any way to any drug and deﬁnitely not

to vaccines. Some reported SE are either normal physiologic processes such as teething,

while others could be developmental conditions such as ﬁssured tongue [

]. Monitoring

the safety of COVID-19 vaccines is an important and ongoing process that should also

be accurate. In the US, Vaccine Adverse Event Reporting System has been implemented

as an active surveillance system, during the initial implementation phases of the COVID-

19 national vaccination program [

]. A similar system is being adopted in Europe by

individual national authorities, in collaboration with the European Centre for Disease

Prevention and Control and European Medicine Agency (EMA) [9].

In Jordan at least 524,533 doses of COVID-19 vaccines have been administered as of

15 April 2021, which are enough to vaccinate about 2.6% of the population utilizing the

two-dose regimen [

]. Unfortunately, little research has been published on COVID-19

clinical outcomes in Jordan and as far as we know no research has been conducted there on

either efﬁcacy or safety of its vaccines so far.

The study included three vaccines and it investigated SE after ﬁrst and second doses

separately because we aimed to collect as many responses as possible, and to explore

possible variations in reactions between ﬁrst and second doses. It is important at this critical

stage of the vaccination campaign to reassure vaccine recipients by collecting evidence-

based data about the local and systemic SE especially if these effects have a transient or

temporary nature which might abolish fears and encourage completion of the two-dose

vaccination series [

], and booster doses in the future if need arises. The three vaccines

included in this study were PB (an mRNA vaccine), AZ vaccine-Vaxzevria, (adenovirus

vector encoding the S glycoprotein of SARS-CoV-2), and SP (inactivated vaccine). PB and

AZ vaccines are being distributed on a wide scale and their SE are being continuously

documented and reported. On the other hand, there is little information on SP vaccine in

terms of its efﬁcacy and safety. Currently, a limited number of countries adopted SP in

their vaccination campaigns including Jordan, United Arab Emirates, Bahrain, Egypt and

Peru [11]. Hence, it is important to provide data on this particular vaccine as well.

Approximately one in ﬁve and one in three did not have side effects after the ﬁrst

and second dose, respectively. The lower rate of side effects in second dose recipients

noticed in this study is probably correlated to the variation in numbers of various vaccine

recipients among ﬁrst and second dose recipients. Less than 4% of the second dose

recipients (compared to 44% of ﬁrst dose recipients) have received AZ vaccine which was

found to be the one highly associated with side effects. On the other hand, approximately

45% of second dose recipients have received SP vaccine, the one with minimal side effects.

Most participants who received SP vaccine did not report any side effects after any of

the two doses indicating the weak immunogenic potential of the vaccine. Inactivated

vaccines are said to have a good safety proﬁle, however, they need a booster plan to create

immune memory [

]. Most participants had local side effects associated with post-injection

pain and numbness. Among systemic side effects, fatigue represented the most common

symptom after both ﬁrst and second doses. Other cited side effects included myalgia,

headache, fever, arthralgia, and bone pain. According to Centers of Disease Control

and Prevention (CDC), the common adverse effects of COVID-19 vaccines include pain,

swelling and redness at injection site, as well as fatigue, chills, fever, myalgia, headache,

and nausea [

]. A minority of participants reported gastrointestinal side effects (nausea,

Vaccines 2021, 9, 577 8 of 10

vomiting, diarrhea), respiratory side effects (dyspnea), and there were some sporadic cases

of ear symptoms, facial pain, sleepiness, and diuresis.

PB vaccine SE were reported in literature as fatigue, chills, headache, myalgia, and

pain at the injection site. Such adverse events were dose-dependent and were more

common after the second immunization [

]. This is consistent with our study wherein

PB vaccine was signiﬁcantly associated with headache, fever, fatigue, myalgia and joint

pain after the second dose. This vaccine can also rarely cause anaphylactic shock [

According to Medicines and Healthcare Products Regulatory Agency (MHRA), it has been

advised to administer the vaccine with caution to individuals who have any history of an

allergic reaction to a vaccine, drug or food and especially people who need an adrenaline

auto-injector in emergency cases [

]. In comparison to other COVID-19 vaccines it is more

temperature sensitive, consequently, it is harder to store and transport [

]. None of our

participants reported allergic reaction to PB vaccine.

The most severe side effects were correlated with AZ vaccine (>90% of vaccine recipi-

ents), while the PB was signiﬁcantly associated with severity of local side effects (46% of

PB vaccine recipients). It was reported that Vaxzevria had mild adverse reactions including

chills, fatigue, headache, fever, nausea, muscle aches, malaise, and painful injection sites

within a week post-vaccination [

]. As a prophylactic measure, paracetamol was recom-

mended to reduce these post-vaccination local and systemic reactions [16]. It was noticed

that there were not signiﬁcant differences between males and females in development of

systemic side effects, however, participants who were 45 years or younger had signiﬁcantly

more systemic side effects. Vaxzevria was described as being better tolerated in older

adults than in younger adults and has similar immunogenicity across all age groups after

a boost dose [

]. Most of the reported local and systemic adverse events in the literature

were mild to moderate in severity, and it was found that booster vaccination was associated

with fewer adverse effects than the ﬁrst dose of vaccination and reactogenicity reduced

with increasing age [

]. Age restrictions in vaccine selection have been applied in several

countries. Although the MHRA recommended against age restrictions in AZ vaccine use,

the Joint Committee on Vaccination and Immunisation (JCVI) in the UK advised that people

younger than 30 should be offered alternative vaccines where available [

]. Currently,

several countries inside and outside Europe have put age restrictions to AZ vaccine recip-

ients [

]. If there are going to be age restrictions in Jordan as well, there is a possibility

that a large sector of the population will be offered other alternatives because the median

age is estimated to be 23.8 years. Of interest are the gastrointestinal symptoms affecting

recipients of AZ vaccine. The vaccine was found to be clearly associated with diarrhea,

nausea and vomiting. This may be explained by the nature of this vaccine (S glycoprotein)

and its inﬂuence on the gastrointestinal system, an inﬂuence that was previously elucidated

for SARS-CoV-2 itself [

]. No serious SE are being reported by our study. According

to EMA, 30 cases of thromboembolic events (predominantly venous) had been reported

by 10 March 2021, among the approximately 5 million recipients of the Vaxzevria in the

European Economic Area [

]. It is recommended that people who have persistent and

very severe headaches within the ﬁrst 2–3 weeks after vaccination get further evaluation.

A safety update released by the EMA on 16 April 2021 speciﬁed thrombocytopenia as a

new common side effect (in <1 in 10 persons) and thrombosis in combination with throm-

bocytopenia as a new very rare side effect (in <1 in 10,000 persons). Side effects included

shortness of breath, chest or persistent abdominal pain, leg swelling, severe or persistent

headache, blurred vision, persistent bleeding, and skin bruising or round, pinpoint spots

beyond the site of vaccination appearing after a few days [

]. Recently, Østergaard et al.

(2021) did a nationwide analysis of population-based data from Denmark to estimate the

natural incidence of venous thromboembolism and compare it to that related to Vaxzevria,

and there was no difference [

]. In tackling this issue, it is important to address the

difference in sociodemographics and lifestyle factors among different nations. In Jordan

other possible confounders may exist. The role of several psychological triggers related to

the COVID-19 pandemic was suggested in a recent study investigating the development of

Vaccines 2021, 9, 577 9 of 10

acute myocardial infarction in Jordanian non-COVID-19 patients [

]. These confounders

were found to be lockdown stress, loneliness, unstable income, unemployment, binge

smoking, anger and fear of contracting COVID-19 infection [

]. Some participants in this

study reported headache, dyspnea, tinnitus and facial pain. Whether this is related to the

vaccine needs to be further veriﬁed. Two cases of herpes zoster were also reported as a side

effect in this study. This infection, as well as several recurrent herpes infections, is a known

complication for depressed immunity. The inﬂuence of the SARS-CoV-2 on the immune

system, and its ability to stimulate recurrent opportunistic viral infections of the skin and

mucous membranes are already established [

]. Similarly, it seems that the inﬂuence of

the vaccine on the immune system should not be underestimated.

Our study included three vaccines, two of them have attracted attention worldwide.

SP vaccine has been under the spotlight because of its rather “quiet” proﬁle, while AZ

vaccine has been surrounded by noise in several pivotal areas of the world. The results of

this study conﬁrmed that SP is really a “quiet” vaccine since it was signiﬁcantly associated

with symptom-free vaccination. However, these ﬁndings neither conﬁrm its efﬁcacy, nor

exclude its long-term SE. On the other hand, AZ vaccine was found to be most signiﬁcantly

associated vaccine with post vaccination side effects. However, it should be noted that no

serious SE were reported, and that recovery in all affected participants was achieved in a

duration of days.

It was not the aim of this study to investigate efﬁcacy of vaccines, however, ﬁve par-

ticipants considered COVID-19 infection as a side effect. Contracting COVID-19 infection

after being vaccinated is consistent with the less than 100% efﬁcacy rate that the produc-

ers of COVID-19 vaccines reported after both doses. Vaccine effectiveness in preventing

COVID-19 was reported to be 95% for PB [

] and 70.4% for AZ vaccine [

]. As for SP the

picture is not yet clear, with efﬁcacy ranging from 50% to 78% according to trials conducted

on this vaccine in some countries [11].

There were limitations in this study owing to the cross-sectional, self-reported design

and the possibility that psychological factors may have inﬂuenced participants’ perceptions.

Another limitation is that the study did not investigate medical status of participants, and

how this could have inﬂuenced their responses to the vaccines. Therefore, we cannot rule

out the inﬂuence of medical status as an important confounder in determining vaccine SE.

Not all our participants have received the second dose yet because it is to be taken in the

near future. It was important to include all those who received one or two doses due to

the urgent and ongoing nature of vaccine evaluation. Further, response rate could not be

determined because at the time of conducting this study the total number of vaccinated

healthcare workers in Jordan was not yet known. Therefore, we included a convenient

sample. The main strength of this study is that the study sample was derived from

healthcare professionals who are expected to provide transparent information based on

their medical and scientiﬁc background.

It is recommended that longitudinal surveys are conducted over the coming years

to investigate possible long-term SE of vaccines. Alongside these surveys, other surveys

should be conducted to examine the efﬁcacy of these vaccines in preventing COVID-19,

and the best regimen in booster vaccination.

Author Contributions:

Conceptualization, O.A.-H., S.A.-H., N.D.-O.; methodology, A.A. and H.B.;

resources, A.A.-H. and F.Q.; data curation, H.A., and I.N.; writing—original draft preparation,

O.A.-H.

and A.A.-H.; writing—review and editing, N.D.-O. and S.A.-H.; ethical approval, H.A. All

authors have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Institutional Review Board Statement:

This study received unconditional approval by Research

Ethics committee of School of Nursing, University of Jordan, Amman, Jordan. IRB#PF.21.14.

Informed Consent Statement:

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: Data can be obtained from corresponding author upon request.

Vaccines 2021, 9, 577 10 of 10

Conﬂicts of Interest: The authors declare no conﬂict of interest.

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