Archives of Academic Emergency Medicine. 2023; 11(1): e22 OR I G I N A L RE S E A RC H Short-term Side Effects of mRNA-based COVID-19 Vaccine Among Jordanian Population; a Cross-sectional Study Razan I. Nassar1∗ 1. Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan. Received: October 2022; Accepted: December 2022; Published online: 12 February 2023 Abstract: Introduction: One type of the developed COVID-19 vaccines that received emergency permission and was approved by the food and drug administration (FDA) is the mRNA-based vaccine. The aim of this study is to gather information on the Jordanian population’s experience with the vaccine’s side effects. Methods: The study objectives were addressed through a cross-sectional study, which collected information regarding the short-term side effects experienced by the vaccinated individuals within one month following the injection of an mRNA-based COVID-19 vaccine. Data collection was carried out in August 2021. Participants were invited to take part in a self-administered web-based survey created using Google Forms. Results: Among the study’s participants (n= 533), about 56% experienced side effects after the first dose of the mRNA-based COVID-19 vaccine. The most commonly reported side effects after the first dose were sore arm at the injection site (91.6%), and fatigue (83.06%). The female gender was significantly associated with experiencing fatigue, discomfort, chills, and hair loss. Being over 30 years old was significantly associated with experiencing cough. Being a smoker was significantly associated with experiencing shortness of breath and gastrointestinal symptoms. Conclusion: The mRNA-based COVID-19 vaccine side effects were common, yet, mild, local, and self-limited. The local pain at the injection site was the most commonly reported side effect. Hopefully, the study’s findings will aid in lowering resistance to vaccination. Keywords: Coronavirus; COVID-19; adverse effects; vaccines; mRNA vaccine; COVID-19 vaccines; Jordan Cite this article as: I. Nassar R. Short-term Side Effects of mRNA-based COVID-19 Vaccine Among Jordanian Population; a Cross-sectional Study. Arch Acad Emerg Med. 2023; 11(1): e22. https://doi.org/10.22037/aaem.v11i1.1850. 1. Introduction In December 2019, the novel coronavirus (SARS-CoV-2) was first recognized in Wuhan, China. It causes a highly infec- tious disease referred to as COVID-19 (1). The COVID-19 has spread globally to turn into a worldwide pandemic (2). Healthcare providers, policymakers, governments, and re- searchers were eagerly working around the clock to provide sufficient prevention and treatment modalities to fight the pandemic (3). Worldwide, several preventive measures were imposed by the governments in order to reduce the spread of the virus and the burden on the healthcare sector; for ex- ample, quarantine and social distancing were imposed, also wearing a face mask was made mandatory in public places (4, 5). The public health emergency needed urgent efforts to de- velop and test the vaccines to combat the COVID-19 pan- ∗Corresponding Author: Razan I. Nassar; Applied Science Private University, Amman 11931, Jordan, P. O. Box 166, Email: r_nassar@asu.edu.jo, Phone: W +9626 5609999, M +962 799770094, ORCID: https://orcid.org/0000-0001-8952- 0376. demic (3). Thus, several vaccines were developed and granted emergency approval (6). One type of the developed vaccines is the mRNA-based COVID-19 vaccine, which was approved by the United States Food and Drug Administration in December 2020 (7). To get fully vaccinated with the mRNA- based vaccine, two doses are required; the second dose must be administered at least three weeks after the first dose. The vaccine can provide efficient protection one week after the second dose (8). In January 2021, Jordan was one of the first countries to launch vaccination campaigns, giving emphasis to health- care professionals and the elderly (9). Despite the govern- ment’s continuous attempts to guarantee that most of the population is vaccinated; myths, fear, safety concerns, and negative beliefs have adversely shaped the perception of the public, which in turn affected the percentage of infected in- dividuals. Variation in public awareness and perception toward vac- cines is generally documented (10-12). Furthermore, hes- itancy is another major factor that influenced the decision of the individual whether to receive the vaccine or not (11, 12). Hesitancy associated with getting vaccinated is com- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index R. I. Nassar 2 mon, partly due to the fact that the COVID-19 vaccines were rapidly developed (13). Concerns and fears of individuals who are hesitant to vaccinate should be addressed. This calls for urgent public transparency and engagement (12). Thus, it is crucial to collect data regarding COVID-19 vac- cines’ side effects in order to educate and clarify to the public what to anticipate post-vaccination. This information may contribute to increasing confidence in COVID-19 vaccines, as well as, decreasing hesitancy. Hence, the aim of this study is to gather information on the Jordanian population’s experience with the COVID-19 vac- cine’s immediate side effects. 2. Methods 2.1. Study design and settings The study objectives were addressed through a cross- sectional study, which was performed to collect information regarding the short-term side effects experienced by the vac- cinated individuals within one month following the injection of an mRNA-based COVID-19 vaccine. Data collection was carried out in August 2021. Participants were invited to take part in a self-administered web-based survey created using Google Forms. The survey was adjusted in a way that allows the participant to send one response only. Ethical approval for this study was obtained from the Institu- tional Review Board Committee at the Faculty of Pharmacy, Applied Science Private University (Ethics code: 2021-PHA- 31). Participation in the study was voluntary. Informed con- sent to participate in the study was provided by participants. 2.2. Participants Eligibility criteria included residing in Jordan, and having re- ceived at least one dose of the mRNA-based COVID-19 vac- cine. Individuals living in any geographic area were allowed to participate in the study. Participants should have the abil- ity to provide their information by completing the online sur- vey. 2.3. Data gathering The survey items were selected based on the existing infor- mation regarding the side effects of the mRNA-based COVID- 19 vaccine (Pfizer-BioNTech®). Following an extensive re- view of the literature on PubMed, Google Scholar, and other databases, the first draft of the survey was developed (8, 14, 15). The survey questions were reviewed to merge concepts and eliminate unrelated items. Three experts in the field reviewed the first draft to ensure its face and content validity, then the survey was updated based on their feedback. Assessment criteria were sent to them (ap- propriateness of the words used, clarity of items, suitability of content, consistency of survey style and its layout). They informed the research team that the survey is clear, compre- hensive, the items are relevant to the study objectives and suitable for the study’s aim. Moreover, they confirmed that the study survey is free from difficult terminology and medi- cal jargon. To assess the clarity of words and item comprehension, a pi- lot study was conducted. The pilot study participants were excluded from the analysis of the current study, and addi- tional amendments were conducted based on their sugges- tions. To finalize, the questions were re-evaluated to make them concise and suitable for online administration (format, sequencing, general clarity, and graphic layout). The final developed survey was organized into two major sec- tions addressing the domains of interest. The first section in- cluded items to collect participants’ demographic data, such as gender, age, marital status, educational level, employ- ment, living place, and nationality. Additionally, the follow- ing information was also collected; whether they were smok- ers, had any chronic disease(s), whether they were using any medication(s), and if they were previously infected with COVID-19. The second section included items that aimed to collect information regarding the side effects experienced following the injection of mRNA-based COVID-19 vaccine; the following data were collected: the date of vaccination (month), the number of doses that were taken (one or two doses), and the side effects that were experienced after re- ceiving each dose. Additionally, in this section, participants were asked if they needed hospitalization within a month of receiving the vaccine, and they were requested to select the dose that caused the most severe side effects. 2.4. Survey implementation Study participants were recruited through social media (mainly Facebook and WhatsApp). As the first step in par- ticipants’ selection, they were asked if they had received the first dose of the mRNA-based COVID-19 vaccine. This ques- tion should be answered with ‘Yes’ in order to be able to open the survey. Eligible participants who indicated a willingness to participate in this study were also able to open a link to see the study’s ethics committee approval letter, and afterward, they were able to complete the survey. Communication between the researcher and the participants was established via e-mail when needed. The survey was de- signed to take less than five minutes to be completed. 2.5. Statistical analyses The sample size was determined based on population and the number of vaccinated individuals in Jordan. It was calcu- lated to be a minimum of 384 participants, using a margin of error of 5%, a confidence level of 95%, and a response distri- bution of 50% (16). The survey responses were coded and entered into a cus- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 3 Archives of Academic Emergency Medicine. 2023; 11(1): e22 Table 1: Demographic characteristics of the studied participants (n= 533) Parameter Number (%) Gender Male 119 (22.3) Female 414 (77.7) Age (year) < 18 8 (1.5) 18-29 219 (41.1) 30-39 195 (36.6) 40-49 75 (14.1) 50-59 27 (5.1) ≥ 60 9 (1.7) Marital Status Married 294 (55.0) Single 217 (40.7) Divorced 20 (3.8) Widowed 2 (0.4) Living place Amman (the Capital) 403 (75.6) Other cities 130 (24.4) Nationality Jordanian 491 (92.1) Non-Jordanian 42 (7.9) Educational level Primary school 6 (1.1) Some high school 27 (5.1) High school diploma 35 (6.6) Bachelor’s degree 367 (68.9) Postgraduate degree (Master’s or PhD) 98 (18.4) Employment Employed 282 (52.9) Not employed 236 (44.3) Retired 15 (2.8) Smoker Yes 154 (28.9) No 365 (68.5) Previous smoker 14 (2.6) tomized database using the Statistical Package for the So- cial Sciences (SPSS), Version 24.0 (IBM Corp., Armonk, New York, USA). Qualitative variables were presented as percent- ages. Fisher’s exact test was used to assess the association be- tween each side effect after the first dose of the mRNA-based COVID-19 vaccine and participants’ gender, age, and smok- ing status. The p-value cutoff for significance was established at 0.05. 3. Results 3.1. Baseline characteristics of studied cases The survey was distributed to 545 participants; however, 12 individuals refused to participate in the current study leaving a response rate of 97.8%. The detailed demographic charac- teristics of the participants are listed in Table 1. The majority of the study’s participants were female (77.7%), about 43% of the participants were less than 30 years old, more than half of the participants (55.0%) were married, 92.1% had a Jorda- nian nationality, and 87.3% had a bachelor’s or postgraduate degree. More than half of the participants were employed (52.9%), and about one-third of the participant were smok- ers (28.9%). The most common comorbidity among the participants was allergy (19.5%). The percentages of other comorbidities were low, ranging from 0.4% (chronic obstructive pulmonary dis- ease) to 6.6% (thyroid diseases). More than half of the par- ticipants (52.7%) were not infected prior to receiving the mRNA-based COVID-19 vaccine, whereas, 37.9% had been affected with COVID-19 prior to vaccination, and the remain- ing (9.4%) were unsure. In May 2021, 26.1% of the study’s participants had received the first dose of the mRNA-based COVID-19 vaccine, while the lowest percentage was reported in January 2021 (2.1%). 3.2. Side effects Regarding the side effects after the first dose of the mRNA- based COVID-19 vaccine, 300 (56.3%) cases reported expe- riencing various side effects. The most common side effect that was reported by the participants was sore arm at the site of injection (91.6%). Fatigue and tiredness (83.6%), discom- fort (69.6%), muscle/joint pain (60.3%), drowsiness (59.0%), and headache (57.6%) were reported by more than half of the participants (Figure 1). Association between side effects after the first dose of the mRNA-based COVID-19 vaccine and participants’ gender, age, and smoking status were investigated. As shown in Fig- ure 2, there is a significant association between the female gender and experiencing fatigue (p = 0.033), discomfort (p = 0.013), chills (p = 0.003), and hair loss (p-value= 0.017). A significant association was found between being older than 30 and experiencing cough (p = 0.046). Furthermore, a sig- nificant association was found between being a smoker and experiencing shortness of breath (p = 0.042), and gastroin- testinal symptoms (p = 0.049). Out of the 533 participants, 402 (75.4%) had received the sec- ond dose of the mRNA-based COVID-19 vaccine. Among those participants (n= 402), about 66.0% (n= 267) experi- enced side effects after the second dose of the mRNA-based COVID-19 vaccine. The most common side effect that was reported by the par- ticipants after the second dose was a sore arm at the site of injection (88.8%). Fatigue, discomfort, muscle/joint pain, headache, and drowsiness were also reported by more than half of the participants (Figure 1). More than half (58.8%) of the study participants who had side effects after both doses stated that the second dose was ac- companied by more severe side effects; in contrast, 24.7% This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index R. I. Nassar 4 Figure 1: Side effects reported by the study’s participants after receiving the first dose (n= 300) and the second dose (n= 267) of the mRNA- based COVID-19 vaccine (the difference was only significant for drowsiness (p = 0.033)). chose the first dose, and 16.5% said there was no difference between the two doses. A statistically significant increase (p < 0.000) was found in the proportion of the participants who experienced side ef- fects after the second dose (66.4%) compared to the first dose. Moreover, as shown in figure 1, drowsiness was the only side effect that showed a significant difference in the propor- tion of participants who experienced it following the first and This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 5 Archives of Academic Emergency Medicine. 2023; 11(1): e22 Figure 2: Association between experiencing side effects and gender, age, and smoking status among the study’s participants. the second dose of the mRNA-based COVID-19 vaccine (p = 0.033). 4. Discussion This is the first cross-sectional study conducted on the Jor- danian population to specifically assess the side effects of mRNA-based COVID-19 vaccine. Receiving the COVID-19 vaccine is a major intervention toward containing the pan- demic. However, it has been faced with hesitancy (17-19). Limited data about the COVID-19 vaccines development ac- count for the high level of uncertainty and hesitancy toward COVID-19 vaccine acceptance (17). Hesitancy toward receiv- ing the COVID-19 vaccine should be addressed. Thus, sim- ilar to the current study, several studies were conducted to reveal side effects associated with COVID-19 vaccines in or- der to provide the general public with data regarding COVID- 19 vaccines, which in turn would decrease hesitancy and ex- plain to the public what to expect after the vaccination (8, 13, 15, 20-26). Global vaccination campaigns have been launched to stop the COVID-19 pandemic. Real-world observing of COVID-19 vaccine safety is still crucial even though clinical trial studies revealed that the majority of COVID-19 vaccines have excel- lent safety and efficacy profiles. In the current study, sore arm at the injection site, fatigue, discomfort, muscle/joint pain, drowsiness, and headache were reported by more than half of the participants who experienced side effects (300 out of 533 participants for the first dose, and 267 out of 402 par- ticipants for the second dose) after both doses. These find- ings are in line with several published studies, and are con- sistent with the side effects listed by the United States Cen- ters for Disease Control and Prevention (CDC) (27). For ex- ample, in Saudi Arabia, a survey-based study was conducted to assess the side effects of mRNA-based COVID-19 vaccine, 386 participants completed the survey. The most commonly reported side effects were local pain, fatigue, and muscle pain (79.3%, 42.0%, 39.1%, respectively) (28). Another cross- sectional study conducted in Saudi Arabia documented that the most common side effects reported by the participants were injection site pain, and headache (8). Moreover, a cross- sectional study was conducted among healthcare workers in Czech Republic (15). Injection site pain (89.8%), fatigue (62.2%), headache (45.6%), muscle pain (37.1%), and chills (33.9%) were the most frequently reported side effects expe- rienced by the study participants (n= 877). Moreover, the side effects were more common among older participants (≤/≥43-year-old group) (15). Another cross-sectional study was conducted among healthcare workers (n= 803 received the mRNA-based COVID-19 vaccine), and the most common side effects reported by more than half of the participants This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index R. I. Nassar 6 were localized, generalized, and musculoskeletal symptoms (89.5%, 76.0%, 53.3%, respectively) (29). The reported rates of side effects have varied between conducted studies due to differences in race, age, and underlying conditions. A recent systemic review was undertaken to assess the mRNA-based COVID-19 vaccine side effects. The most fre- quently reported side effects among the total number of the participants (n= 10,632) in all articles (107 were screened, and 14 were included) were injection site pain, fatigue, mus- cle pain, local swelling, and headache (77.3%, 43.0%, 39.7%, 33.6%, 33.3%, respectively) (30). The review findings were in line with the current study findings, as the most commonly reported side effect among the current study’s population was sore arm at the injection site. It is obvious that injection site pain was the most commonly reported side effect among most of the studies conducted on different populations (31-33). Moreover, local pain continues to be the most frequent side effect observed in multiple vac- cine trials conducted in the past (34). The reason behind this finding may be explained by the fact that several factors con- tribute to the pain at the injection site such as the technique used for injection, injection velocity, and vaccine tempera- ture. These factors are challenging to standardize and will have a significant impact on a person’s experience (35). It is advised to lower the arm that will be receiving the injection in order to reduce the pain, as an injection into a relaxed mus- cle causes less pain. Furthermore, it is recommended that the medical staff participating in the vaccination process acquire proper training on the best injection technique to lessen dif- ferences in the way individuals experience pain after vacci- nation (36). Males and females react to vaccination differently. As docu- mented in a systemic review, the rate of experienced side ef- fects is usually higher in females compared to males (69.8%, 30.2%, respectively) (30). Being female, was a statistically significant factor for experiencing higher number of side ef- fects in two cross-sectional studies conducted in Saudi Ara- bia (8, 28). Various other published studies observed a gen- der difference, with females experiencing significantly more side effects compared to males (37, 38). This is consistent with the current study’s findings. Moreover, the current study revealed that the female gender is significantly associated with experiencing fatigue, discomfort, chills, and hair loss. This is probably due to a combination of biological factors, such as hormones and genes. Additionally, sex variation in pharmacodynamics and pharmacokinetics have been exam- ined, with females being more susceptible to side effects (39). A medical officer at the CDC’s Immunization Safety Office stated that women have more reactions to a range of vac- cines. This covers both adult influenza and some childhood vaccinations, such as the hepatitis B, and measles, mumps, and rubella (MMR) vaccines (40). On the other hand, these findings should not be deemed bad news for women, as firstly, the side effects were mild, and self-limited, and sec- ondly, interestingly, these physical responses indicate that the vaccine is effective and working. According to the results of the current study, experiencing cough was significantly associated with being older than 30. Several studies assessed the relationship between age and side effects. Baden et al. found that younger participants (18-64 years old) experienced side effects more frequently than participants over the age of 65 (41). Another survey- based study conducted among German healthcare workers revealed that younger participants were more affected by the systemic side effects compared to the older age partic- ipants following receiving the mRNA-based COVID-19 vac- cine (67.4% vs. 54.5%) (26). The authors’ decision to use a different age cutoff in each study may account for the vari- ance in the studies’ findings. More than half of the current study’s participants stated that the second dose was accompanied by more severe side ef- fects. Two cross-sectional studies conducted in Saudi Ara- bia documented similar results, the first one recorded that after the second dose, higher numbers of side effects were reported by the participants compared to the first dose (28), and the second one indicated a significant increase in the proportion of respondents who experienced side effects after receiving the second dose compared to the first dose (8). Ac- cording to the data collected by the CDC from mRNA-based COVID-19 vaccine recipients in the United States, more side effects were recorded after the second dose. Furthermore, equivalent findings were generated by the FDA (42), and sev- eral other studies (37). 5. Limitations This study comes with some limitations. The study was based on an online survey, and this might be a source of se- lection bias. However, web-based recruitment of participants was found to be cost-effective, facilitating the reach of people who are otherwise difficult to reach, and representative (43, 44). In Jordan, around 90% of the population have internet access, which makes them easy to reach using online-based ques- tionnaires. Another limitation of this study is that it was con- ducted while the vaccination campaign was still ongoing in Jordan; therefore, the delayed side effects may not have been reported. 6. Conclusions The current study reveals the side effects associated with the mRNA-based COVID-19 vaccine, which were common, yet, mild, local, and self-limited. The local pain at the injection site was the most commonly reported side effect. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index 7 Archives of Academic Emergency Medicine. 2023; 11(1): e22 7. Declarations 7.1. Acknowledgments None. 7.2. Conflict of interest The author declares no relevant conflicts of interest or finan- cial relationships. 7.3. Fundings and supports This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 7.4. Authors’ contribution R.N: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Data Curation, Writing - Original Draft Preparation, Writing- Review and Editing. References 1. Sharma O, Sultan AA, Ding H, Triggle CR. A Review of the Progress and Challenges of Developing a Vaccine for COVID-19. Frontiers in immunology. 2020;11:585354. 2. COVID live - Coronavirus statis- tics - worldometer. [Available from: https://www.worldometers.info/coronavirus/? 3. Kaur RJ, Dutta S, Bhardwaj P, Charan J, Dhingra S, Mitra P, et al. Adverse events reported from COVID-19 vaccine trials: a systematic review. Indian Journal of Clinical Bio- chemistry. 2021;36(4):427-39. 4. The Jordan Times. Jordan Strategy Forum paper strate- gises over coronavirus policy 2020 [Available from: https://www.jordantimes.com/news/local/jordan- strategy-forum-paper-strategises-over-coronavirus- policy. 5. Alqutob R, Al Nsour M, Tarawneh MR, Ajlouni M, Khader Y, Aqel I, et al. COVID-19 crisis in Jordan: Response, sce- narios, strategies, and recommendations. JMIR public health and surveillance. 2020;6(3):e19332. 6. Craven J. COVID-19 Vaccine Tracker 2021 [Available from: https://www.raps.org/news-and-articles/news- articles/2020/3/covid-19-vaccine-tracker. 7. U.S. Food and Drug Administration. FDA Briefing Document. Pfizer-BioNTech COVID-19 Vaccine 2020 [Available from: https://www.fda.gov/media/144245/download. 8. El-Shitany NA, Harakeh S, Badr-Eldin SM, Bagher AM, Eid B, Almukadi H, et al. Minor to moderate side ef- fects of Pfizer-BioNTech COVID-19 vaccine among Saudi residents: a retrospective cross-sectional study. Interna- tional journal of general medicine. 2021:1389-401. 9. Al-Junaidi L. Jordan begins COVID-19 vaccine rollout 2021 [Available from: https://www.aa.com.tr/en/latest- on-coronavirus-outbreak/jordan-begins-covid-19- vaccine-rollout/2108497. 10. Batarseh YS, Darwish ElHajji FW, Shammas S, Darwish RM, Fakhoury R, Al Haj Ahmad M, et al. Perception and attitude of the public on vaccine practices and pharma- cists as immunizers in Jordan. Journal of Pharmaceutical Health Services Research. 2021;12(2):114-21. 11. Adedeji-Adenola H, Olugbake OA, Adeosun SA. Factors influencing COVID-19 vaccine uptake among adults in Nigeria. PLoS One. 2022;17(2):e0264371. 12. Enitan S, Oyekale A, Akele R, Olawuyi K, Olabisi E, Nwankiti A, et al. Assessment of knowledge, perception and readiness of Nigerians to participate in the COVID- 19 vaccine trial. International Journal of Vaccines and Immunization. 2020;4(1):1-13. 13. Saeed BQ, Al-Shahrabi R, Alhaj SS, Alkokhardi ZM, Adrees AO. Side effects and perceptions following Sinopharm COVID-19 vaccination. International Journal of Infec- tious Diseases. 2021;111:219-26. 14. World Health Organization. Vaccines and immuniza- tion: What is vaccination? 2021 [Available from: https://www.who.int/news-room/questions-and- answers/item/vaccines-and-immunization-what-is- vaccination?adgroupsurvey=adgroupsurvey&gclid=CjwK CAjwoP6LBhB. 15. Riad A, Pokorná A, Attia S, Klugarová J, Koščík M, Klugar M. Prevalence of COVID-19 vaccine side effects among healthcare workers in the Czech Republic. Journal of clin- ical medicine. 2021;10(7):1428. 16. Eng J. Sample size estimation: how many individuals should be studied? Radiology. 2003;227(2):309-13. 17. Alhassan RK, Aberese-Ako M, Doegah PT, Immurana M, Dalaba MA, Manyeh AK, et al. COVID-19 vaccine hesi- tancy among the adult population in Ghana: evidence from a pre-vaccination rollout survey. Tropical Medicine and Health. 2021;49(1):1-13. 18. Al-Turk F, Akour A, Farha RA. The impact of an ed- ucational workshop on counteracting hesitancy to- ward the COVID-19 vaccine among pharmacy students in Jordan. Journal of Applied Pharmaceutical Science. 2022;12(8):095-101. 19. Qunaibi EA, Helmy M, Basheti I, Sultan I. A high rate of COVID-19 vaccine hesitancy in a large-scale survey on Arabs. Elife. 2021;10:e68038. 20. Nassar RI, Alnatour D, Thiab S, Nassar A, El-Hajji F, Basheti IA. Short-term side effects of COVID-19 vaccines: A cross-sectional study in Jordan. Human Vaccines & Im- munotherapeutics. 2022;18(5):2082792. 21. Abu-Hammad O, Alduraidi H, Abu-Hammad S, Alnaz- zawi A, Babkair H, Abu-Hammad A, et al. Side effects This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index R. I. Nassar 8 reported by Jordanian healthcare workers who received COVID-19 vaccines. Vaccines. 2021;9(6):577. 22. Dar-Odeh N, Abu-Hammad O, Qasem F, Jambi S, Al- hodhodi A, Othman A, et al. Long-term adverse events of three COVID-19 vaccines as reported by vaccinated physicians and dentists, a study from Jordan and Saudi Arabia. Human Vaccines & Immunotherapeutics. 2022;18(1):2039017. 23. Almufty HB, Mohammed SA, Abdullah AM, Merza MA. Potential adverse effects of COVID19 vaccines among Iraqi population; a comparison between the three avail- able vaccines in Iraq; a retrospective cross-sectional study. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2021;15(5):102207. 24. Omeish H, Najadat A, Al-Azzam S, Tarabin N, Abu Hameed A, Al-Gallab N, et al. Reported COVID-19 vac- cines side effects among Jordanian population: a cross sectional study. Human vaccines & immunotherapeu- tics. 2022;18(1):1981086. 25. Hatmal MmM, Al-Hatamleh MA, Olaimat AN, Hatmal M, Alhaj-Qasem DM, Olaimat TM, et al. Side effects and perceptions following COVID-19 vaccination in Jordan: a randomized, cross-sectional study implementing ma- chine learning for predicting severity of side effects. Vac- cines. 2021;9(6):556. 26. Klugar M, Riad A, Mekhemar M, Conrad J, Buchbender M, Howaldt H-P, et al. Side effects of mRNA-based and viral vector-based COVID-19 vaccines among German healthcare workers. Biology. 2021;10(8):752. 27. Centers for Disease Control and Preven- tion. Possible Side Effects 2022 [Available from: https://www.cdc.gov/coronavirus/2019- ncov/vaccines/expect/after.html. 28. Mohammed RA, Garout RM, Wahid S, Ayub F, ZinAld- din LMF, Sultan I. A survey on the side effects of Pfizer/BioNTech COVID-19 vaccine among vaccinated adults in Saudi Arabia. Cureus. 2021;13(11). 29. Kadali RA, Janagama R, Peruru S, Malayala SV. Side ef- fects of BNT162b2 mRNA COVID-19 vaccine: A random- ized, cross-sectional study with detailed self-reported symptoms from healthcare workers. International Jour- nal of Infectious Diseases. 2021;106:376-81. 30. Dighriri IM, Alhusayni KM, Mobarki AY, Aljerary IS, Alqurashi KA, Aljuaid FA, et al. Pfizer-BioNTech COVID- 19 vaccine (BNT162b2) side effects: a systematic review. Cureus. 2022;14(3). 31. Cuschieri S, Borg M, Agius S, Souness J, Brincat A, Grech V. Adverse reactions to Pfizer-BioNTech vaccination of healthcare workers at Malta’s state hospital. Interna- tional journal of clinical practice. 2021;75(10):e14605. 32. Riad A, Hocková B, Kantorová L, Slávik R, Spurná L, Stebel A, et al. Side effects of mRNA-based COVID-19 vaccine: nationwide phase IV study among healthcare workers in Slovakia. Pharmaceuticals. 2021;14(9):873. 33. Im JH, Kim E, Lee E, Seo Y, Lee Y, Jang Y, et al. Ad- verse events with the Pfizer-BioNTech COVID-19 vaccine among Korean healthcare workers. Yonsei Medical Jour- nal. 2021;62(12):1162. 34. Nichol KL, Margolis KL, Lind A, Murdoch M, McFadden R, Hauge M, et al. Side effects associated with influenza vaccination in healthy working adults: a randomized, placebo-controlled trial. Archives of Internal Medicine. 1996;156(14):1546-50. 35. Ozdemir L, Akay BN, Akyol A. Effect of methylpred- nisolone injection speed on the perception of intra- muscular injection pain. Pain Management Nursing. 2013;14(1):3-10. 36. Centers for Disease Control and Prevention. Training and Education 2021 [Available from: https://www.cdc.gov/vaccines/covid-19/training- education/index.html. 37. Lee YW, Lim SY, Lee J-H, Lim JS, Kim M, Kwon S, et al. Adverse reactions of the second dose of the BNT162b2 mRNA COVID-19 vaccine in healthcare workers in Korea. Journal of Korean medical science. 2021;36(21). 38. Alamer E, Alhazmi A, Qasir NA, Alamer R, Areeshi H, Go- hal G, et al. Side effects of COVID-19 Pfizer-BioNtech mRNA vaccine in children aged 12–18 years in Saudi Ara- bia. Vaccines. 2021;9(11):1297. 39. Zucker I, Prendergast BJ. Sex differences in pharmacoki- netics predict adverse drug reactions in women. Biology of sex differences. 2020;11:1-14. 40. The New York Times. Women Report Worse Side Effects After a Covid Vaccine 2021 [Available from: https://www.nytimes.com/2021/03/08/health/vaccine- side-effects-women-men.html. 41. Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. New England journal of medicine. 2021;384(5):403-16. 42. U.S. Food and Drug Administration. FDA Review of Ef- ficacy and Safety of Pfizer-BioNTech COVID-19 Vaccine Emergency Use Authorization Request 2020 [Available from: https://www.fda.gov/media/144337/download. 43. Fenner Y, Garland SM, Moore EE, Jayasinghe Y, Fletcher A, Tabrizi SN, et al. Web-based recruiting for health research using a social networking site: an exploratory study. Journal of medical Internet research. 2012;14(1):e1978. 44. Cantrell MA, Lupinacci P. Methodological issues in online data collection. Journal of advanced nursing. 2007;60(5):544-9. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: https://journals.sbmu.ac.ir/aaem/index.php/AAEM/index Introduction Methods Results Discussion Limitations Conclusions Declarations References