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Influenza vaccination among nurses in Greece
American Journal of Infection Control 40 (2012) 276-8
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Influenza vaccination among nurses in Greece Aikaterini Toska RN, MSc, PhD a, Maria Saridi RN, MSc, PhD a, Greta Wozniak MD, PhD b, *, Kyriakos Souliotis PhD c, Konstantinos Korovesis MD a, Eleni Apostolopoulou PhD d a
General Hospital of Korinthos, Greece Medical School, University of Thessaly, Larissa, Greece c Faculty of Social Science, University of Peloponnese, Greece d Faculty of Nursing, University of Athens, Athens, Greece b
Key Words: Vaccines Immunization Health care workers
Seasonal influenza has become a serious public health problem worldwide, and vaccination is recognized as the most effective preventative measure. However, data suggest that influenza vaccination rates are generally low among health care workers. The present study showed that the vaccination rates for influenza among nurses are 21.2%. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality in elderly persons and other high-risk individuals. Health care workers (HCWs) can acquire influenza from patients and also can transmit influenza to patients and other staff. Immunization is the most important advance in the control of this infection. Current guidelines from the Advisory Committee of Immunization Practice strongly recommend vaccination of high-risk groups and HCWs for the prevention of nosocomial influenza.1 In Greece, annual influenza vaccination of HCWs has been recommended by the Ministry of Health since 1983 and is offered free of charge. Despite this policy, however, estimated vaccination rates remain low in Greek HCWs.2
information about influenza vaccination and perceptions about the influenza vaccine. The aims of the present study were to estimate the rates of vaccination against influenza among nurses in Greece and to investigate the potential factors associated with the nurses’ acceptance of the vaccination, as well as their level of knowledge regarding influenza vaccination. Cronbach’s a value was used to assess the internal consistency reliability of the study; the value of 0.71 was considered to indicate adequate reliability of the questionnaire. Statistical analyses were performed using SPSS 13.0 (SPSS Inc, Chicago, IL).
RESULTS METHODS This cross-sectional, questionnaire-based survey was conducted by the University of Athens Faculty of Nursing between May 2008 and September 2008 at 17 public hospitals in Greece. The study population consisted of a random sample of 784 nurses working in public hospitals in Athens and other regions in Greece. A selfreported anonymous questionnaire was used, which was prepared and given for pilot testing to 50 nurses working in hospitals other than the study hospitals (to ensure maximum reliability). The questionnaire elicited demographic data as well as * Address correspondence to Greta Wozniak, MD, PhD, Medical School, University of Thessaly, Larissa, Greece. E-mail address: [email protected] (G. Wozniak). Conflict of interest: None to report.
Of the 784 questionnaires distributed to the hospitals, 606 were completed and returned, for a response rate of 77.3%. The study sample included 133 males (21.9%) and 473 females (78.1%). The majority of the participants (47.5%) were aged 30-39 years, and the mean duration of employment was 11 years. Over the previous 5 years, 21.2% of the nurses had received the influenza vaccine between 1 and 3 times each. The nurses were asked to report their reasons for participating in annual influenza vaccination programs. The primary reasons reported for vaccination were self-protection from illness (76.7% of respondents) and protection for their patients (37.2%). The most common reason for not being vaccinated was the belief of being not at risk for infection (44.9%), concerns about adverse reactions (18.9%), and the belief that influenza is not a serious disease (18.8%) (Table 1).
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.04.050
A. Toska et al. / American Journal of Infection Control 40 (2012) 276-8 Table 1 Reported reasons for vaccination and nonvaccination Vaccinated (n ¼ 129), n (%) To protect myself To protect my patients I have a chronic illness It is provided free Other reasons Not vaccinated (n ¼ 479), n (%) No time to get vaccinated at work I am not at risk for influenza Influenza is not a serious illness It was not available during shifts I am afraid of the adverse reactions Other reasons
277
Table 2 Factors influencing influenza vaccination with multiple logistical regression
99 48 7 11 3
(76.7) (37.2) (5.4) (8.5) (2.3)
44 215 90 25 90 51
(9.2) (44.9) (18.8) (5.2) (18.9) (10.6)
The majority of vaccinated nurses (89.9%) reported not having any adverse reactions after vaccination, whereas 11.1% reported side effects from the vaccination, all of which were characterized as mild. Regarding influenza infection and vaccination, 74.4% of the nurses reported that they had not had a respiratory illness over the past 2 years, whereas 25.6% reported having a respiratory illness (probably influenza). Of these, 33.8% were vaccinated and 23.4% were not vaccinated over the same period (P ¼ .024). According to the present study, the mean days of absenteeism due to infection was 2 days. In terms of the nurses’ knowledge level of influenza and vaccination, a significant proportion of respondents (36.5%) reported that HCWs are not at greater risk for influenza than the general public, whereas the majority (84.2%) were aware that they could transmit influenza to their patients. Only 26.8% reported knowing that the vaccine is recommended for HCWs, 5.8% that the vaccine can be safely administered during pregnancy, 63% that the vaccine safely prevents against influenza, and 47.5% that influenza is a highly contagious disease. Logistic regression analysis revealed that increasing age (P ¼ .045) and the belief that vaccination against influenza should be mandatory for HCWs (P ¼ .035) were associated with higher vaccination rates. Multiple logistic regression found that increasing years of employment (P ¼ .002) and the belief that vaccination programs are useful (P ¼ .035), as well as a higher level of knowledge (P < .001) were all associated with higher vaccination rates (Table 2).
Variables Years of employment Belief that the vaccination programs are beneficial High score of knowledge
Odds ratio
95% confidence interval
1.05 1.61
1.02-1.08 1.03-2.51
1.64
1.45-1.87 <.001
P .002 .035
An important finding is the nurses’ overall lack of concern about influenza infection (44.9% of respondents). Fears of side effects and doubts (mistrust) about the vaccine’s effectiveness were the primary reasons for not receiving vaccination cited in other studies.9 The present study found higher rates of respiratory infection in vaccinated nurses (33.8% vs 23.4%; P ¼ .024), in disagreement with previous studies that reported fewer respiratory infections in vaccinated HCWs. This discrepancy might be attributed to the fact that the present survey elicited information about vaccination during the previous 5 years and a history of influenza infection over the previous 2 years. As a result, the HCWs who had been vaccinated 1 or 2 times within the previous 5 years likely had not been vaccinated within the previous 2 years. An alternative theory is that after having experienced symptoms of influenza one year, HCWs opted for vaccination the next year. Previous studies have reported an insignificant difference in risk of illness between vaccinated HCWs and nonvaccinated HCWs, however.12 We found greater absenteeism in vaccinated nurses than in nonvaccinated nurses. Certainly, findings regarding this issue differ among surveys. These differences might be related to the fact that a significant proportion of HCWs continue to work when ill. Our findings demonstrate that nurses’ belief that they pose no risk to patients when ill is strongly associated with nonvaccination. A better understanding of HCWs’ negative attitudes toward influenza vaccination is needed, as are more convincing continuous vaccination programs, to ensure better motivation for influenza vaccination over a longer period. The present study has some limitations. First, we did not analyze the data separately from each hospital to enable useful comparisons of the vaccination levels among hospitals. Second, we investigated vaccination against influenza during the previous 5 years, but the rate of influenza illness only during the previous 2 years. As a result, we do not know whether a respiratory illness occurred before or after vaccination, and whether or not an illness was the reason for vaccination in the subsequent year.
DISCUSSION Although influenza vaccination of HCWs has been recommended for more than 2 decades, the HCW vaccination rate in Greece remains suboptimal.2,3 Low vaccination rates also have been reported worldwide, although some studies have found higher rates than others.4-7 These differences in reported vaccination rates likely are related to the development and implementation of vaccination programs and campaigns, the importance of which has been demonstrated in many studies.8 Self-protection was the primary reason reported for vaccination (76.7%). This finding is in agreement with other surveys,9 but not in others, where the main reason was to reduce absenteeism.10 Accessibility also has been reported as a primary reason for vaccination,11 although this was a minor factor in the present study. Overall, only 37% of nurses reported being vaccinated to protect their patient, likely reflecting lack of knowledge of the nosocomial spread of influenza.
Acknowledgment We thank Rosanna Gonzalez McQuire and the affiliated nurses in the study hospitals (Marios Melekidis, Theodora Joka, Mitroulia Dimitra, Gerakari Stauroula, and Bourvani Pashalia) for their valuable help with this research. References 1. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Recomm Rep 2010;59(RR-08): 1-62. 2. Maltezou HC, Maragos A, Halharapi T, Karagiannis I, Karageorgou K, Remoudaki H, et al. Factor influencing influenza vaccination rates among healthcare workers in Greek hospitals. J Hosp Infect 2007;66:156-9. 3. Dedoukou X, Nikolopoulos G, Maragos A, Giannoulidou S, Maltezou HC. Attitudes towards vaccination against seasonal influenza of healthcare workers in primary health care settings in Greece. Vaccine 2010;28:5931-3.
278
A. Toska et al. / American Journal of Infection Control 40 (2012) 276-8
4. Walker FJ, Singleton JA, Lu P, Wooten KG, Stricas RA. Influenza vaccination of healthcare workers in the United States. Infect Control Hosp Epidemiol 2006; 27:257-65. 5. Leitmeyer K, Buchholz U, Kramer M, Schenkel K, Stahlhut H, Kollstadt M, et al. Influenza vaccination in German health care workers: effects and findings after two rounds of a nationwide awareness campaign. Vaccine 2006;24: 7003-8. 6. Mah MW, Hagen NA, Shepard KP, Hawthorne JS, Mysak M, Lye T, et al. Understanding influenza vaccination attitudes at a Canadian cancer center. Am J Infect Control 2005;33:243-50. 7. Murray SB, Skull SA. Poor health care vaccination coverage and knowledge of vaccination recommendations in a tertiary Australia hospital. Aust NZ J Public Health 2002;26:65-8.
8. Kuranga EM. Improving influenza vaccine rates among health care workers. Am J Infect Control 2006;34:72-3. 9. Takayanagi IJ, Alves Cardoso MR, Costa SF, Araya MA, Machado SM. Attitudes of health care workers to influenza vaccination: why are they not vaccinated? Am J Infect Control 2007;35:56-61. 10. Canning HS, Phillips J, AlIsup S. Health care worker beliefs about influenza vaccine and reasons for no vaccination: a cross-sectional survey. J Clin Nurs 2005;14:922-5. 11. McEwen M, Farren E. Actions and beliefs related to hepatitis B and influenza immunization among registered nurses in Texas. Public Health Nurs 2005;22:230-9. 12. Rizzuto E, Prete AM, Virtuani L, Pompa MG. Effectiveness of influenza vaccination: a survey within the Italian Ministry of Health personnel. Vaccine 2006; 24:6612-4.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Influenza vaccination among nurses in Greece Aikaterini Toska RN, MSc, PhD a, Maria Saridi RN, MSc, PhD a, Greta Wozniak MD, PhD b, *, Kyriakos Souliotis PhD c, Konstantinos Korovesis MD a, Eleni Apostolopoulou PhD d a
General Hospital of Korinthos, Greece Medical School, University of Thessaly, Larissa, Greece c Faculty of Social Science, University of Peloponnese, Greece d Faculty of Nursing, University of Athens, Athens, Greece b
Key Words: Vaccines Immunization Health care workers
Seasonal influenza has become a serious public health problem worldwide, and vaccination is recognized as the most effective preventative measure. However, data suggest that influenza vaccination rates are generally low among health care workers. The present study showed that the vaccination rates for influenza among nurses are 21.2%. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality in elderly persons and other high-risk individuals. Health care workers (HCWs) can acquire influenza from patients and also can transmit influenza to patients and other staff. Immunization is the most important advance in the control of this infection. Current guidelines from the Advisory Committee of Immunization Practice strongly recommend vaccination of high-risk groups and HCWs for the prevention of nosocomial influenza.1 In Greece, annual influenza vaccination of HCWs has been recommended by the Ministry of Health since 1983 and is offered free of charge. Despite this policy, however, estimated vaccination rates remain low in Greek HCWs.2
information about influenza vaccination and perceptions about the influenza vaccine. The aims of the present study were to estimate the rates of vaccination against influenza among nurses in Greece and to investigate the potential factors associated with the nurses’ acceptance of the vaccination, as well as their level of knowledge regarding influenza vaccination. Cronbach’s a value was used to assess the internal consistency reliability of the study; the value of 0.71 was considered to indicate adequate reliability of the questionnaire. Statistical analyses were performed using SPSS 13.0 (SPSS Inc, Chicago, IL).
RESULTS METHODS This cross-sectional, questionnaire-based survey was conducted by the University of Athens Faculty of Nursing between May 2008 and September 2008 at 17 public hospitals in Greece. The study population consisted of a random sample of 784 nurses working in public hospitals in Athens and other regions in Greece. A selfreported anonymous questionnaire was used, which was prepared and given for pilot testing to 50 nurses working in hospitals other than the study hospitals (to ensure maximum reliability). The questionnaire elicited demographic data as well as * Address correspondence to Greta Wozniak, MD, PhD, Medical School, University of Thessaly, Larissa, Greece. E-mail address: [email protected] (G. Wozniak). Conflict of interest: None to report.
Of the 784 questionnaires distributed to the hospitals, 606 were completed and returned, for a response rate of 77.3%. The study sample included 133 males (21.9%) and 473 females (78.1%). The majority of the participants (47.5%) were aged 30-39 years, and the mean duration of employment was 11 years. Over the previous 5 years, 21.2% of the nurses had received the influenza vaccine between 1 and 3 times each. The nurses were asked to report their reasons for participating in annual influenza vaccination programs. The primary reasons reported for vaccination were self-protection from illness (76.7% of respondents) and protection for their patients (37.2%). The most common reason for not being vaccinated was the belief of being not at risk for infection (44.9%), concerns about adverse reactions (18.9%), and the belief that influenza is not a serious disease (18.8%) (Table 1).
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.04.050
A. Toska et al. / American Journal of Infection Control 40 (2012) 276-8 Table 1 Reported reasons for vaccination and nonvaccination Vaccinated (n ¼ 129), n (%) To protect myself To protect my patients I have a chronic illness It is provided free Other reasons Not vaccinated (n ¼ 479), n (%) No time to get vaccinated at work I am not at risk for influenza Influenza is not a serious illness It was not available during shifts I am afraid of the adverse reactions Other reasons
277
Table 2 Factors influencing influenza vaccination with multiple logistical regression
99 48 7 11 3
(76.7) (37.2) (5.4) (8.5) (2.3)
44 215 90 25 90 51
(9.2) (44.9) (18.8) (5.2) (18.9) (10.6)
The majority of vaccinated nurses (89.9%) reported not having any adverse reactions after vaccination, whereas 11.1% reported side effects from the vaccination, all of which were characterized as mild. Regarding influenza infection and vaccination, 74.4% of the nurses reported that they had not had a respiratory illness over the past 2 years, whereas 25.6% reported having a respiratory illness (probably influenza). Of these, 33.8% were vaccinated and 23.4% were not vaccinated over the same period (P ¼ .024). According to the present study, the mean days of absenteeism due to infection was 2 days. In terms of the nurses’ knowledge level of influenza and vaccination, a significant proportion of respondents (36.5%) reported that HCWs are not at greater risk for influenza than the general public, whereas the majority (84.2%) were aware that they could transmit influenza to their patients. Only 26.8% reported knowing that the vaccine is recommended for HCWs, 5.8% that the vaccine can be safely administered during pregnancy, 63% that the vaccine safely prevents against influenza, and 47.5% that influenza is a highly contagious disease. Logistic regression analysis revealed that increasing age (P ¼ .045) and the belief that vaccination against influenza should be mandatory for HCWs (P ¼ .035) were associated with higher vaccination rates. Multiple logistic regression found that increasing years of employment (P ¼ .002) and the belief that vaccination programs are useful (P ¼ .035), as well as a higher level of knowledge (P < .001) were all associated with higher vaccination rates (Table 2).
Variables Years of employment Belief that the vaccination programs are beneficial High score of knowledge
Odds ratio
95% confidence interval
1.05 1.61
1.02-1.08 1.03-2.51
1.64
1.45-1.87 <.001
P .002 .035
An important finding is the nurses’ overall lack of concern about influenza infection (44.9% of respondents). Fears of side effects and doubts (mistrust) about the vaccine’s effectiveness were the primary reasons for not receiving vaccination cited in other studies.9 The present study found higher rates of respiratory infection in vaccinated nurses (33.8% vs 23.4%; P ¼ .024), in disagreement with previous studies that reported fewer respiratory infections in vaccinated HCWs. This discrepancy might be attributed to the fact that the present survey elicited information about vaccination during the previous 5 years and a history of influenza infection over the previous 2 years. As a result, the HCWs who had been vaccinated 1 or 2 times within the previous 5 years likely had not been vaccinated within the previous 2 years. An alternative theory is that after having experienced symptoms of influenza one year, HCWs opted for vaccination the next year. Previous studies have reported an insignificant difference in risk of illness between vaccinated HCWs and nonvaccinated HCWs, however.12 We found greater absenteeism in vaccinated nurses than in nonvaccinated nurses. Certainly, findings regarding this issue differ among surveys. These differences might be related to the fact that a significant proportion of HCWs continue to work when ill. Our findings demonstrate that nurses’ belief that they pose no risk to patients when ill is strongly associated with nonvaccination. A better understanding of HCWs’ negative attitudes toward influenza vaccination is needed, as are more convincing continuous vaccination programs, to ensure better motivation for influenza vaccination over a longer period. The present study has some limitations. First, we did not analyze the data separately from each hospital to enable useful comparisons of the vaccination levels among hospitals. Second, we investigated vaccination against influenza during the previous 5 years, but the rate of influenza illness only during the previous 2 years. As a result, we do not know whether a respiratory illness occurred before or after vaccination, and whether or not an illness was the reason for vaccination in the subsequent year.
DISCUSSION Although influenza vaccination of HCWs has been recommended for more than 2 decades, the HCW vaccination rate in Greece remains suboptimal.2,3 Low vaccination rates also have been reported worldwide, although some studies have found higher rates than others.4-7 These differences in reported vaccination rates likely are related to the development and implementation of vaccination programs and campaigns, the importance of which has been demonstrated in many studies.8 Self-protection was the primary reason reported for vaccination (76.7%). This finding is in agreement with other surveys,9 but not in others, where the main reason was to reduce absenteeism.10 Accessibility also has been reported as a primary reason for vaccination,11 although this was a minor factor in the present study. Overall, only 37% of nurses reported being vaccinated to protect their patient, likely reflecting lack of knowledge of the nosocomial spread of influenza.
Acknowledgment We thank Rosanna Gonzalez McQuire and the affiliated nurses in the study hospitals (Marios Melekidis, Theodora Joka, Mitroulia Dimitra, Gerakari Stauroula, and Bourvani Pashalia) for their valuable help with this research. References 1. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Recomm Rep 2010;59(RR-08): 1-62. 2. Maltezou HC, Maragos A, Halharapi T, Karagiannis I, Karageorgou K, Remoudaki H, et al. Factor influencing influenza vaccination rates among healthcare workers in Greek hospitals. J Hosp Infect 2007;66:156-9. 3. Dedoukou X, Nikolopoulos G, Maragos A, Giannoulidou S, Maltezou HC. Attitudes towards vaccination against seasonal influenza of healthcare workers in primary health care settings in Greece. Vaccine 2010;28:5931-3.
278
A. Toska et al. / American Journal of Infection Control 40 (2012) 276-8
4. Walker FJ, Singleton JA, Lu P, Wooten KG, Stricas RA. Influenza vaccination of healthcare workers in the United States. Infect Control Hosp Epidemiol 2006; 27:257-65. 5. Leitmeyer K, Buchholz U, Kramer M, Schenkel K, Stahlhut H, Kollstadt M, et al. Influenza vaccination in German health care workers: effects and findings after two rounds of a nationwide awareness campaign. Vaccine 2006;24: 7003-8. 6. Mah MW, Hagen NA, Shepard KP, Hawthorne JS, Mysak M, Lye T, et al. Understanding influenza vaccination attitudes at a Canadian cancer center. Am J Infect Control 2005;33:243-50. 7. Murray SB, Skull SA. Poor health care vaccination coverage and knowledge of vaccination recommendations in a tertiary Australia hospital. Aust NZ J Public Health 2002;26:65-8.
8. Kuranga EM. Improving influenza vaccine rates among health care workers. Am J Infect Control 2006;34:72-3. 9. Takayanagi IJ, Alves Cardoso MR, Costa SF, Araya MA, Machado SM. Attitudes of health care workers to influenza vaccination: why are they not vaccinated? Am J Infect Control 2007;35:56-61. 10. Canning HS, Phillips J, AlIsup S. Health care worker beliefs about influenza vaccine and reasons for no vaccination: a cross-sectional survey. J Clin Nurs 2005;14:922-5. 11. McEwen M, Farren E. Actions and beliefs related to hepatitis B and influenza immunization among registered nurses in Texas. Public Health Nurs 2005;22:230-9. 12. Rizzuto E, Prete AM, Virtuani L, Pompa MG. Effectiveness of influenza vaccination: a survey within the Italian Ministry of Health personnel. Vaccine 2006; 24:6612-4.