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Association between health care workers’ knowledge of influenza vaccine and vaccine uptake

Published:October 31, 2013DOI:https://doi.org/10.1016/j.ajic.2013.06.020
      Immunization is the most effective measure available to prevent influenza and its complications, and health care workers (HCWs) play a pivotal role. We conducted a cross-sectional survey study to determine HCWs knowledge and opinions regarding influenza vaccine and its acceptance at our institution. The most important reason for vaccine uptake was because it required formal declination (33%); physicians were more likely to be vaccinated because of patient care, whereas nurses were more likely to be vaccinated because it required formal declination.

      Key Words

      Immunization is the most effective measure available to prevent influenza and its complications, and health care workers (HCWs) play a pivotal role.

      The National Vaccine Advisory Committee. Recommendations on strategies to achieve the Healthy People 2020 annual influenza vaccine coverage goal for health care personnel. Available from: http://www.hhs.gov/nvpo/nvac/subgroups/healthcare_personnel_influenza_vacc_subgroup.html. Accessed March 15, 2013.

      WHO Influenza (seasonal) fact sheet number 211. Available from: http://www.who.int/mediacentre/factsheets/fs211/en/index.html#. Accessed April 22, 2011.

      Vaccine uptake (VU) among HCWs is cost-effective and associated with decreased absenteeism and patient mortality.
      • Potter J.
      • Stott D.J.
      • Roberts M.A.
      • Elder A.G.
      • O’Donnell B.
      • Knight P.V.
      • et al.
      Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients.
      • Carman W.F.
      • Elder A.G.
      • Wallace L.A.
      • McAulay K.
      • Walker A.
      • Murray G.D.
      • et al.
      Effects of influenza vaccination of health-care workers on mortality of elderly people living in long-term care: a randomized controlled trial.
      HCWs knowledge and/or opinions regarding vaccine are important and can directly and indirectly affect patient care.
      • Burls A.
      • Jordan R.
      • Barton P.
      • Olowokure B.
      • Wake B.
      • Albon E.
      • et al.
      Vaccinating healthcare workers against influenza to protect the vulnerable. Is it a good use of health care resources? A systematic review of the evidence and an economic evaluation.

      Methods

      Vaccination was voluntary at our institution prior to 2010 and resulted in compliance rates ranging from 40% to 60%. Our institution adopted a policy for the 2010-2011 season and beyond that stated all employees who refused vaccine were required to sign a declination form. Offered reasons for declination included a medical contraindication, religious belief, or personal preference. Those not vaccinated were required to don a mask at all times while in patient care areas during the designated influenza season. Overall compliance during the 2010-2011 season was 95%, significantly higher compared with 55% from the previous season (P < .0001).
      During the 2010-2011 season, we conducted a cross-sectional, self-administered survey of nursing staff, attending and resident physicians, and medical students at the Medical University of South Carolina to determine their knowledge and opinion about influenza vaccine and if such correlated with VU. The χ2 or Fisher exact test was used to compare categorical data (SAS version 9.3; SAS Institute, Cary, NC).

      Results

      Six hundred eighty-nine (21%) of 3,281 surveys were completed: 14% of respondents were medical students, 15% were physicians (15% at the attending level), and 71% were nursing staff (93% registered nurses).
      Among respondents, compared with the 2009-2010 season, significantly more were vaccinated in 2010-2011 (73% vs 94%, respectively, P < .0001). Also, compared with HCWs who declined the 2009-2010 vaccine, those who received the vaccine were more likely to be vaccinated in 2010-2011 (P < .0001). Among 2010-2011 vaccine recipients, the most important reason for VU was the requirement for declination (33%) followed by protecting personal health (28%) and concern about patients (26%). Physicians were more likely than nurses to receive vaccine because they were concerned about protecting patients (44% vs 23%, respectively, P < .001). There was no difference in VU between resident level physicians and attending level physicians or between registered nurses and non-registered nurses. With regard to vaccine knowledge and/or opinion, 88% of physicians compared with 67% of nurses agreed it was unlikely for vaccine to cause severe reaction (P < .0001), 69% of physicians compared with 42% of nurses agreed that vaccine was effective in preventing influenza (P < .0001), and 84% of physicians compared with 70% of nurses agreed they were unlikely to contract influenza after vaccination (P = .0025).
      Significantly more HCWs in the vaccinated group stated that vaccine was effective in reducing their chances of getting influenza or in reducing severity of illness if they contracted it compared with those who declined vaccine (52% vs 12%, respectively, P < .0001). Interestingly, 43% of HCWs who declined vaccine provided no specific reason other than “personal preference”; 18% were concerned about adverse effects, and 16% declined because of “influenza-like illness with previous vaccination.” Among HCWs who declined vaccination, only 4% had a medical contraindication.

      Discussion

      Immunization of HCWs has been associated with decreased nosocomial transmission and decreased patient mortality.
      • Potter J.
      • Stott D.J.
      • Roberts M.A.
      • Elder A.G.
      • O’Donnell B.
      • Knight P.V.
      • et al.
      Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients.
      • Salgado C.D.
      • Giannetta E.T.
      • Hayden F.G.
      • Farr B.M.
      Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians.
      • Salgado C.D.
      • Farr B.M.
      • Hall K.K.
      • Hayden F.G.
      Influenza in the acute hospital setting.
      Our institution experienced a 40% increase in VU after requiring a declination statement for all HCWs not accepting vaccine and requiring them to don a mask during the declared influenza season, and the results of our survey would suggest that this requirement was a major reason for the increase. Our increase in VU compares favorably with that reported from other institutions (ranging from 11.6% to 23.5%) when declination was required.
      • Ribner B.S.
      • Hall C.
      • Steinburg J.P.
      • Bornstein W.A.
      • Chakkalakal R.
      • Emamifar A.
      • et al.
      Use of mandatory declination form in a program for influenza vaccination of healthcare workers.
      • Bertin M.
      • Scarpelli M.
      • Proctor A.W.
      • Sharp J.
      • Robitson E.
      • Donnelly T.
      • et al.
      Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program.
      • Polgreen P.M.
      • Septimus E.T.
      • Parry M.F.
      • Beekmann S.E.
      • Cavanaugh J.E.
      • Srinivasin A.
      • et al.
      Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals.
      • Quan K.
      • Tehrani D.M.
      • Dickey L.
      • Spiritus E.
      • Hizon D.
      • Heck K.
      • et al.
      Voluntary to mandatory: evolution of strategies and attitudes toward influenza vaccination of healthcare personnel.
      Like others, our study revealed that hospital staff who had previously received vaccine were more likely to receive subsequent vaccine.
      • Begue R.E.
      • Gee S.Q.
      Improving influenza immunization among healthcare workers.
      The reasons for VU among nurses and physicians in our study agree with that of Martinello et al, who documented a similar knowledge gap among nurses but not physicians.
      • Martinello R.A.
      • Jones L.
      • Topal J.E.
      Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt.
      Forty-four percent of physicians received the vaccine because of patient care compared with only 23% of nurses. Patient care should be a prominent reason to receive vaccine because immunization of HCWs is critical for protecting those at risk from health care-associated influenza. Given that patient care was the main reason for VU among our physicians, this may suggest a shift in culture that emphasizes patient safety and prevention of adverse events. This study was conducted at an academic medical center and may not be generalizable to all providers. Our study is also limited by a low response rate and potentially by selection bias introduced by the use of a self-administered survey.
      Reasons for VU in our cohort further buttress the point that we have progressed slowly in increasing voluntary vaccination rates among HCWs. Our findings mirror that of other organizations that have demonstrated that voluntary programs are less effective, in part, because HCWs have misconceptions regarding the risks and benefits of vaccine.
      Various studies have looked at barriers for VU.
      • Hofmann F.
      • Ferracin C.
      • Marsh G.
      • Dumas R.
      Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs.
      • Heimberger T.
      • Chang H.G.
      • Shaikh M.
      • Crotty L.
      • Morse D.
      • Birkhead G.
      Knowledge and attitudes of healthcare workers about influenza: why are they not getting vaccinated?.
      • Stephenson I.
      • Roper J.P.
      • Nicholson K.G.
      Healthcare workers and their attitudes to influenza vaccination.
      Barriers have included fear of adverse reactions, misconceptions that “vaccination can cause influenza” or that they are not “at risk,” and having unsuitable locations and times for vaccination. In our study, the majority of HCWs that declined vaccination, declined without any reason; it was a “personal preference.”
      There must be focused education among HCWs about the benefits of vaccination, morbidity and mortality of influenza, and the fact that HCWs play a pivotal role as educators of patients as well as transmitters of disease. HCWs may receive a “mandated” vaccine or may be required to “formally decline” but may not recommend or offer the vaccine if there is a deficit of knowledge about the role of influenza vaccine in health maintenance.
      Health care organizations must continue to assuage common fears and misconceptions about influenza and the vaccine by conducting regular educational activities emphasizing the impact of influenza infection, the benefits of influenza vaccination, and the scientific facts about the efficacy and adverse effects of influenza vaccine.

      References

      1. The National Vaccine Advisory Committee. Recommendations on strategies to achieve the Healthy People 2020 annual influenza vaccine coverage goal for health care personnel. Available from: http://www.hhs.gov/nvpo/nvac/subgroups/healthcare_personnel_influenza_vacc_subgroup.html. Accessed March 15, 2013.

      2. WHO Influenza (seasonal) fact sheet number 211. Available from: http://www.who.int/mediacentre/factsheets/fs211/en/index.html#. Accessed April 22, 2011.

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