Article

Sensitivity to COVID-19 Vaccine Effectiveness and Safety in

Shanghai, China
Jia Lu 1 , Xiaosa Wen 1 , Qi Guo 1 , Mengdi Ji 2 , Felicia Zhang 2 , Abram L. Wagner 2, * and Yihan Lu 3

1 Department of Immunizations, Minhang Centers for Disease Control and Prevention, Shanghai 201101,
China; [email protected] (J.L.); [email protected] (X.W.); [email protected] (Q.G.)
2 Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109, USA;
[email protected] (M.J.); [email protected] (F.Z.)
3 Key Laboratory of Public Health Safety (Ministry of Education), Fudan University School of Public Health,
Shanghai 200433, China; [email protected]
* Correspondence: [email protected]

Abstract: Several COVID-19 vaccines have been on the market since early 2021 and may vary in
their effectiveness and safety. This study characterizes hesitancy about accepting COVID-19 vaccines
among parents in Shanghai, China, and identifies how sensitive they are to changes in vaccine
safety and effectiveness profiles. Schools in each township of Minhang District, Shanghai, were
sampled, and parents in the WeChat group of each school were asked to participate in this cross-
sectional Internet-based survey. Parents responded to questions about hesitancy and were given
information about five different COVID-19 vaccine candidates, the effectiveness of which varied
between 50 and 95% and which had a risk of fever as a side effect between 5 and 20%. Overall,
3673 parents responded to the survey. Almost 90% would accept a vaccine for themselves (89.7%),
for their child (87.5%) or for an elderly parent (88.5%) with the most ideal attributes (95% effectiveness





 with 5% risk of fever). But with the least ideal attributes (50% effectiveness and a 20% risk of fever)
Citation: Lu, J.; Wen, X.; Guo, Q.;
these numbers dropped to 33.5%, 31.3%, and 31.8%, respectively. Vaccine hesitancy, age at first
Ji, M.; Zhang, F.; Wagner, A.L.; Lu, Y. child’s birth, and relative income were all significantly related to sensitivity to vaccine safety and
Sensitivity to COVID-19 Vaccine effectiveness. Parents showed a substantial shift in attitudes towards a vaccine based on its safety
Effectiveness and Safety in Shanghai, and effectiveness profile. These findings indicate that COVID-19 vaccine acceptance may be heavily
China. Vaccines 2021, 9, 472. https:// influenced by how effective the vaccine actually is and could be impeded or enhanced based on
doi.org/10.3390/vaccines9050472 vaccines already on the market.

Academic Editor: Ralph A. Tripp Keywords: COVID-19 vaccination; vaccine hesitancy; China; urban health

Received: 23 March 2021

Accepted: 29 April 2021
Published: 7 May 2021
1. Introduction

Publisher’s Note: MDPI stays neutral

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes
with regard to jurisdictional claims in
coronavirus disease [1], has led to substantial morbidity and mortality worldwide and put
published maps and institutional affil-
considerable pressure on public health systems. Since the outbreak, the need for a vaccine,
iations. one of the most powerful and cost-effective tools for preventing disease in large populations,
has never been more urgent [2]. Unlike previous vaccines, which required years or even
decades of clinical trial research, vaccines against COVID-19 were developed at “warp
speed” [3,4], much more quickly than previous vaccines [5]. More than 50 COVID-19
vaccine candidates are currently in trials, and several vaccines have already been approved
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
and distributed. By 14 January 2021, more than 35 million doses in 49 countries had been
This article is an open access article
administered [6].
distributed under the terms and
A vaccine is only useful if people are willing to receive it. Various countries started
conditions of the Creative Commons rolling out vaccines in late 2020, prioritizing healthcare and other essential workers and
Attribution (CC BY) license (https:// those with high-risk health conditions. However, members of the general population
creativecommons.org/licenses/by/ may be hesitant to receive a vaccine due to concerns over the speed of its development
4.0/). and concerns about safety and effectiveness. Vaccine hesitancy is already listed as one of

Vaccines 2021, 9, 472. https://doi.org/10.3390/vaccines9050472 https://www.mdpi.com/journal/vaccines

Vaccines 2021, 9, x FOR PEER REVIEW 2 of 8

Vaccines 2021, 9, 472 2 of 8

concerns about safety and effectiveness. Vaccine hesitancy is already listed as one of the
top 10 global health threats, so hesitancy over these new drugs may exacerbate vaccine
refusal [7]. According to a survey conducted in 19 countries, 71.5% of the respondents
would
the topconsider
10 globaltaking
healthathreats,
COVID-19 vaccine over
so hesitancy [8]. This
thesehesitancy
new drugs andmayrefusal may intensify
exacerbate vaccine
the pandemic
refusal and put more
[7]. According pressure
to a survey on health in
conducted systems.
19 countries, 71.5% of the respondents
would consider study
A previous takingshowed
a COVID-19 vaccine [8]. This
that respondents fromhesitancy
China showedand refusal may intensify
the highest positive
the pandemic
response (88.6%)andandputlowest
more pressure
negative on health (0.7%)
response systems.when asked if they would accept a
A previous
“proven, safe andstudy showed
effective that respondents
COVID-19 vaccine” [8].from China sensitivity
However, showed thetohighest positive
different levels
response
of (88.6%)
effectiveness and
and lowest
safety negative
within Chinaresponse
was still (0.7%) when
unclear. asked
It is also if they
not would
clear whataccept
factorsa
“proven,
may havesafe and effective
influenced their COVID-19
acceptance.vaccine” [8]. However,
It is crucial to consider sensitivity
the public’s to different levels
acceptance of
of effectiveness and safety within China was still unclear. It is also not
vaccines that have different levels of safety and effectiveness and the factors related to clear what factors
may have
them influenced
to adopt their acceptance.
evidence-based It is crucial
interventions to consider
for varying vaccine thelevels
public’s acceptance
to counter of
future
vaccines that
outbreaks. have
This different
study levels ofvaccine
characterizes safety and effectiveness
hesitancy towards and thethe factors related
COVID-19 vaccineto
them toparents
among adopt evidence-based
in Shanghai, China,interventions for varying
and identifies vaccine
how sensitive levels
they are to
to counter
changes future
in the
outbreaks.
vaccine safetyThis
andstudy characterizes
effectiveness vaccine hesitancy towards the COVID-19 vaccine
profile.
among parents in Shanghai, China, and identifies how sensitive they are to changes in
the
2. vaccine safety
Materials and effectiveness profile.
and Methods
2.1. Study Population
2. Materials and Methods
In thisPopulation
2.1. Study study, a stratified cluster sampling method was used to conduct a question-
naire Insurvey in each
this study, of the 13
a stratified townships
cluster sampling in method
Minhangwas District,
used toShanghai.
conduct aWe wanted a
questionnaire
sample size of 2345 to have a margin of error of at least 2% for our outcome:
survey in each of the 13 townships in Minhang District, Shanghai. We wanted a sample size the proportion
who
of 2345would accept
to have a given
a margin of vaccine
error of with alpha
at least of 0.05.
2% for We obtained
our outcome: a larger sample
the proportion given
who would
the easeaatgiven
accept obtaining
vaccinedata within
with alpha schools. Within
of 0.05. each township,
We obtained a largera convenience
sample givensample of
the ease
one school was chosen. In each sampled school, a health instructor
at obtaining data within schools. Within each township, a convenience sample of one sent the questionnaire
link
schoolto each class’s WeChat
was chosen. In eachgroup.
sampled Following
school, athis, the parents
health instructorof sent
the students filled out
the questionnaire
the questionnaire. In order to improve the controllability of the questionnaire’s
link to each class’s WeChat group. Following this, the parents of the students filled out source, the
fidelity of the sampling, and the participation of the parents, researchers
the questionnaire. In order to improve the controllability of the questionnaire’s source, answered any
parents’ questions
the fidelity live during
of the sampling, andthethe
survey completion;
participation questionnaires
of the that were
parents, researchers completed
answered any
in less than
parents’ 5 min (estimated
questions live duringtime) were excluded
the survey completion; from the data analysis.
questionnaires Thecompleted
that were question-
naire
in lesswas
than developed by stafftime)
5 min (estimated at thewere
Minhang Centers
excluded fromfortheDisease ControlThe
data analysis. andquestionnaire
Prevention.
was developed by staff at the Minhang Centers for Disease Control and Prevention.
2.2. Derived Variables
2.2. Derived
VaccineVariables
hesitancy was assessed through a 10-item adult Vaccine Hesitancy Scale
(aVHS) Vaccine hesitancy
(Figure 1). This was assessed through
questionnaire had beena validated
10-item adult
by U.S.Vaccine Hesitancy
and Chinese Scale
samples
(aVHS) (Figure 1). This questionnaire had been validated by U.S. and Chinese
[9], and within this sample there was high internal reliability of this scale (Standardizedsamples [9],
and within this sample there was high internal reliability of this scale (Standardized
Crohnbach’s alpha = 0.82). Briefly, each item was based on a 5-point Likert scale: a score
Crohnbach’s
of alpha
1 represented the=lowest
0.82). Briefly,
degreeeach item was
of vaccine based on
hesitancy anda 5-point Likert scale:
5 the highest). The aresults
score
of 1 represented
were summed forthe lowest range
a possible degreeofof10vaccine
to 50. Ahesitancy
score of 10and 5 the
to 24 washighest). The as
categorized results
“not
were summed
hesitant”, whilefor
25atopossible
50 was range of 10 to
considered 50. A score
“hesitant” [9].of 10 to 24 was categorized as “not
hesitant”, while 25 to 50 was considered “hesitant” [9].

Figure 1. Responses to questions about vaccine hesitancy among parents of school-aged children in Shanghai, China, 2020.
Questions with an asterisk (*) have been reverse coded so that all questions have responses with higher values being more
vaccine hesitant.
Vaccines 2021, 9, 472 3 of 8

We assessed acceptance of a vaccine first by providing participants with different

profiles of effectiveness (95, 60 and 50%) and safety (5, 10, and 20% risk of fever). We then
asked parents if they would accept a vaccine with a given profile for themselves, for their
child, or for an elderly parent. From this information, we also if someone were sensitive
to vaccine effectiveness (i.e., they would accept 95% but not 50% effectiveness) or safety
(i.e., they would accept a 5% risk but not a 20% risk of fever). Across each characteristic
(effectiveness and safety) individuals fell into one of three categories: they would not
accept a vaccine under any circumstance; they were sensitive to the profile; or they would
accept any vaccine.
Demographic characteristics of the parents, including their age, second child, and stated
relative income in their peer group, were also collected.

2.3. Statistical Analysis

After quantifying the proportion of individuals with sensitivity to vaccine effectiveness
and safety, we created two multivariable models in which the outcomes were the three-level
characteristics of sensitivity to effectiveness and safety. The primary independent variable
was vaccine hesitancy, as measured by the aVHS. We also included mother vs father, age
of parent, presence of second child, age of first child, sex of first child, and stated relative
income as confounders in this analysis based on an a priori consideration of these variables
with vaccine hesitancy and profile sensitivity. This model output odds ratios (ORs) and
95% confidence intervals (CIs). Data were analyzed in SAS version 9.5 (SAS Institute, Cary,
NC, USA).

3. Results
Overall, 3673 parents responded to the survey. Demographic characteristics of the par-
ents are shown in Table 1. Most respondents (69.1%) were mothers. A plurality (37.1%)
had their first child at 25 to 29 years of age; most (67.2%) did not have a second child; and
for less than half (45.3%), the first child was elementary aged (6–11 years old).

Table 1. Demographic characteristics of a sample of Shanghai parents of school-aged children, 2020.

Count Vaccine Hesitant

Characteristic Category p-Value
(Column %) (Row %)
Mother 2538 (69.1%) 762 (30.0%) 0.3162
Relation to child Father 1093 (29.8%) 306 (28.0%)
Other 42 (1.1%) 15 (35.7%)
18–22 years 346 (9.9%) 67 (19.4%) <0.0001
Age at first 23–25 years 837 (24.0%) 209 (25.0%)
child’s birth 26–29 years 1291 (37.1%) 418 (32.4%)
30–45 years 1010 (29.0%) 324 (32.1%)
No 2412 (67.2%) 758 (31.4%) <0.0001
Second child
Yes 1177 (32.8%) 293 (24.9%)
0–5 years 35 (1.0%) 9 (25.7%) 0.0702
6–11 years 1624 (45.3%) 468 (28.8%)
Age of first child 12–14 years 1133 (31.6%) 338 (29.8%)
15–17 years 555 (15.5%) 181 (32.6%)
≥18 years
Male 1844 (50.8%) 537 (29.1%) 0.6950
Sex of first child
Female 1787 (49.2%) 531 (29.7%)
Less than average 424 (11.5%) 146 (34.4%) 0.0588
Stated relative
About average 2710 (73.8%) 783 (28.9%)
income
More than average 539 (14.7%) 154 (28.6%)
Vaccines 2021, 9, 472 4 of 8

Responses to vaccine hesitancy items are shown in Figure 1. Individuals expressed

a great deal of concern about serious adverse effects (40.1% agreed and 30.1% strongly
agreed), believing that newer vaccines carried more risks than older vaccines (22.2% agreed
and 25.2% strongly agreed), and that vaccines for diseases that were no longer common
were not needed (23.1% agreed and 13.8% strongly agreed).
Overall, 29.5% (1083) were vaccine hesitant, as measured by the aVHS, with some
trends by demographic group. Individuals who were older when they had their first
child (32.1% of those aged 30–45 years) were more hesitant compared to of those who
were 18–22 (19.4%) when they had their first child, (p < 0.0001). Additionally, those with
a second child were less vaccine hesitant (24.9%), compared to those with only one child
(31.4%), (p < 0.0001).
Acceptance of a COVID-19 vaccine varied according to its safety and effectiveness
profile: the highest levels of acceptance were for 95% effectiveness and a 5% risk of fever;
and the lowest were for 50% effectiveness and a 20% risk of fever (Table 2). Almost 90%
would accept a vaccine for themselves (89.7%), for their child (87.5%) or for an elderly
parent (88.5%) if it had the highest attributes. For vaccines with the lowest attributes, these
numbers dropped to 33.5%, 31.3%, and 31.8%, respectively.

Table 2. Acceptance of a COVID-19 vaccine, based on the safety and effectiveness profile.

Sensitivity Condition For Self For Child For Parent

95% effective, 5% risk of fever 3294 (89.7%) 3213 (87.5%) 3250 (88.5%)
95% effective, 20% risk of fever 2330 (63.4%) 2164 (58.9%) 2154 (58.6%)
Acceptance of a vaccine
based on effectiveness and 60% effective, 10% risk of fever 1662 (45.3%) 1569 (42.7%) 1567 (42.7%)
safety profile 50% effective, 5% risk of fever 1790 (48.7%) 1708 (46.5%) 1716 (46.7%)
50% effective, 20% risk of fever 1230 (33.5%) 1151 (31.3%) 1166 (31.8%)
Would not accept any vaccine 369 (10.1%) 453 (12.4%) 413 (11.3%)
Sensitivity to COVID-19 Would accept 95% effective vaccine, not 50% 1514 (41.3%) 1512 (41.2%) 1544 (42.2%)
vaccine effectiveness
Would accept any vaccine 1780 (48.6%) 1701 (46.4%) 1706 (46.6%)
Would not accept any vaccine 363 (9.9%) 445 (12.2%) 405 (11.1%)
Sensitivity to COVID-19 Would accept vaccine with 5% risk of fever,
vaccine safety 980 (26.8%) 1064 (29.1%) 1114 (30.5%)
not 20% risk
Would accept any vaccine 2314 (63.3%) 2149 (58.8%) 2136 (58.4%)

Overall, about 10% of individuals would not accept a vaccine, regardless of its safety
or effectiveness profile; almost half (48.6%) were not sensitive to vaccine effectiveness;
and 31.3% would accept a 95% effective vaccine, but not a 50% effective one. There was
less sensitivity to vaccine safety as measured by risk of fever. Almost two-thirds, 63.3%,
would accept a vaccine regardless of the risk of fever, and about one-fourth, 26.8%, would
accept a vaccine with a 5% risk of fever but not a 20% risk.
Sensitivity to vaccine safety and effectiveness was significantly related to vaccine hesi-
tancy, age at first child’s birth, and stated relative income (Table 3). Having a second child
was significantly related to sensitivity to vaccine effectiveness (p = 0.0334), but not safety
(p = 0.0998). For example, those who were vaccine hesitant were 10.47 times more likely
not to accept a vaccine, and 2.60 times more likely to be sensitive to vaccine effectiveness,
compared to those who were not vaccine hesitant (p < 0.0001). Vaccine hesitancy was
associated with greater odds of not accepting any vaccine or being sensitive to the risk of
fever (p < 0.0001). Those who were younger at their first child’s birth had reduced odds of
not accepting a vaccine or being sensitive to its effectiveness or safety profile (p < 0.0001 for
effectiveness, p = 0.0055 for safety). Those whose income was less than average were less
sensitive, both to the effectiveness profile (p = 0.0035) and to the safety profile (p = 0.0067).
Vaccines 2021, 9, 472 5 of 8

Table 3. Sensitivity to COVID-19 vaccine effectiveness and safety in multinomial logistic regression models among Shanghai
parents of school-aged children, 2020.

Compared to Those Who Would Accept a Compared to Those Who Would Accept a
Vaccine, Regardless of Effectiveness Vaccine, Regardless of Risk of Fever
Characteristic Would Only Accept
Would Not Accept Would Only Accept Would Not Accept
Vaccine With 5% Risk
Any Vaccine, 95% Effective Vaccine, Any Vaccine,
of Fever,
OR (95% CI) OR (95% CI) OR (95% CI)
OR (95% CI)
Vaccine hesitant
No ref ref ref ref
Yes 10.47 (8.03, 13.67) 2.60 (2.19, 3.09) 8.45 (6.54, 10.91) 2.48 (2.09, 2.94)
Relation to child
Mother ref ref ref ref
Father 1.14 (0.87, 1.51) 0.93 (0.79, 1.10) 1.09 (0.83, 1.42) 0.84 (0.70, 1.00)
Age at first child’s birth
18–22 years 0.46 (0.27, 0.79) 0.43 (0.32, 0.58) 0.55 (0.32, 0.94) 0.53 (0.38, 0.74)
23–25 years 0.52 (0.36, 0.75) 0.54 (0.43, 0.66) 0.67 (0.47, 0.97) 0.79 (0.63, 0.99)
26–29 years 0.78 (0.57, 1.05) 0.82 (0.68, 0.99) 0.81 (0.60, 1.09) 0.85 (0.70, 1.03)
30–45 years ref ref ref ref
Have a second child
No ref ref ref ref
Yes 0.75 (0.55, 1.01) 0.83 (0.70, 0.98) 0.81 (0.61, 1.09) 0.84 (0.70, 1.01)
Age of first child
0–5 years 1.37 (0.45, 4.18) 0.67 (0.31, 1.43) 1.65 (0.56, 4.85) 0.82 (0.36, 1.84)
6–11 years ref ref ref ref
12–14 years 1.16 (0.86, 1.55) 1.03 (0.87, 1.22) 1.14 (0.85, 1.51) 0.97 (0.81, 1.16)
15–17 years 1.26 (0.88, 1.79) 0.92 (0.74, 1.15) 1.26 (0.89, 1.79) 0.84 (0.66, 1.06)
≥18 years 1.44 (0.80, 2.60) 0.89 (0.63, 1.26) 1.33 (0.74, 2.39) 0.76 (0.51, 1.14)
Gender of first child
Male ref ref ref ref
Female 0.94 (0.73, 1.21) 1.09 (0.94, 1.26) 0.87 (0.68, 1.12) 0.97 (0.83, 1.13)
Stated relative income
Less than average 0.86 (0.59, 1.28) 0.66 (0.52, 0.84) 1.00 (0.69, 1.46) 0.69 (0.53, 0.91)
About average ref ref ref ref
More than average 1.39 (0.99, 1.96) 1.05 (0.85, 1.29) 1.50 (1.08, 2.09) 1.14 (0.92, 1.42)

4. Discussion
Safety and effectiveness are the two most important indicators for evaluating a new
vaccine, and new vaccines undergo substantial tests of their safety and effectiveness before
and after coming onto the market [10,11]. Previous studies showed that most parents
express concerns about side-effects, safety, and effectiveness [12]. These concerns may be
even more prominent for the COVID-19 vaccine, based on the perceived speed of vaccine
development. Similarly, parents showed a substantial shift in attitudes towards the COVID-
19 vaccine based on safety and effectiveness. The majority of the respondents would accept
a vaccine with high levels of safety and effectiveness, but only one-third would accept
a vaccine with lower levels of safety and effectiveness. These preferences could hamper
Vaccines 2021, 9, 472 6 of 8

acceptance of the vaccine. Interestingly, the public showed a different level of sensitivity
toward safety and effectiveness, with more sensitivity towards effectiveness.
Although vaccines are currently available in some locations, safety and effectiveness
may vary. For example, for two that were approved in the U.S., Pfizer-BioNTech’s vaccine
was 95% and Moderna’s 94.1% efficacious in preventing the COVID-19 disease [13,14].
The AstraZeneca vaccine used in the U.K., India, and Mexico was reported to have an aver-
age efficacy of 70% [15]. For the inactivated vaccines produced by Chinese pharmaceutical
companies, efficacy ranged from 50 to over 90%, depending on the considered outcome
and study site [16]. Currently, 89 vaccines are being tested in clinical trials, and 27 have
reached the final stage [17]. As more vaccines come onto the market, the public may find
itself choosing among vaccines that have widely varying levels of efficacy.
The study found a strong relationship between vaccine hesitancy and COVID-19 vacci-
nation, and the respondents believe that the new vaccine carried more risks than the older
vaccine. The role of vaccine hesitancy, and anti-vaccine movements, has been previously
explored. For instance, Gaulano et al. found that Italian women who received information
from anti-vaccination movements were less likely to accept mandatory vaccines [18]. How-
ever, it is essential to note that people might be hesitant about the COVID-19 vaccine but
not for vaccines in general. The COVID-19 vaccine went through the process from develop-
ment to distribution worldwide at “warp speed.” It also adopted a new approach of using
mRNA, which is different from traditional vaccines that use weakened or inactive compo-
nents of the pathogen [19]. Scientists and governments are still assessing the effectiveness
after the COVID-19 vaccine was authorized for emergency use in the U.S. [20].
COVID-19 vaccine hesitancy is present not only in the general public, but also among
healthcare workers. A recent survey by Kaiser Family Foundation found that nearly
a third of the healthcare workers would probably or definitely refuse the vaccine [21].
Healthcare workers expressed concerns about not enough research having been done;
the lack of adequate transparency among pharmaceutical companies, research companies,
and governments; and fear of being part of another “Tuskegee Study” [22]. Thus, how to
break through the vaccine hesitancy among healthcare workers, who have a higher risk of
contracting the virus and play important roles in their patients’ vaccine decision making,
is of the utmost importance. Even in non-pandemic settings, health care workers have
relatively low coverage of non-mandatory vaccines, and this varied by age, with younger
personnel more likely to be vaccinated [23].

Strengths and Limitations

This is a cross-sectional study and so we were unable to look at longitudinal con-
nections. Additionally, we assessed intent to get a vaccine, but actual vaccine acceptance
may differ as more information becomes available. The vaccine effectiveness and safety
profiles that we chose were based on possible ranges from existing influenza and measles
vaccines, but the actual characteristics of COVID-19 vaccines may differ. We also did not
evaluate acceptance or hesitancy towards other vaccines routinely provided to children,
such as the mumps–measles–rubella vaccine, and did not adjust our analyses for this
variable. Nonetheless, using a large sample of parents, we were able to assess variations in
vaccination intent using a validated vaccination hesitancy scale.

5. Conclusions
In this study of parents of school-aged children in a suburb of Shanghai, parents
showed a substantial shift in attitudes towards the COVID-19 vaccine based on the vaccine’s
safety and effectiveness. The majority of respondents would accept a vaccine with the most
ideal levels of safety and effectiveness, but only one-third would accept vaccines with
the least ideal attributes. These findings indicate that COVID-19 vaccine acceptance may
be substantially influenced by how effective the vaccine actually is. Controlling outbreaks
of COVID-19 in the presence of these strong preferences would require substantial use of
non-pharmaceutical interventions.
Vaccines 2021, 9, 472 7 of 8

Local circumstances are important to consider when developing programs to promote

vaccines, as thoughts about different aspects of vaccination are not uniform across countries.
We did not find consistent associations about education and vaccine hesitancy, in contrast
to prevailing findings about this relationship in high income countries; more work needs to
be done on fully understanding socio-cultural influences on vaccine decision-making. Con-
tinued surveillance of attitudes towards vaccination in low- and middle-income countries
can help identify shifts in future opinions in vaccination attitudes.

Author Contributions: Conceptualization, A.L.W. and Y.L.; Data curation, J.L., X.W. and Q.G.;
Formal analysis, A.L.W.; Investigation, J.L., X.W., Q.G. and Y.L.; Writing—original draft, M.J. and
A.L.W.; Writing—review & editing, J.L., X.W., Q.G., F.Z. and Y.L. All authors have read and agreed to
the published version of the manuscript.
Funding: A.L.W. received salary support from the National Science Foundation, Division of Social
and Economic Sciences (#2027836).
Institutional Review Board Statement: This study has passed the ethical review of the Minhang
District Center for Disease Control and Prevention. EC-P-2020-009.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the cor-
responding author. The data are not publicly available due to personal information contained in
some of the data fields.
Acknowledgments: We appreciate the openness of Minhang schools to participate in this project.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript,
or in the decision to publish the results.

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