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1.  Influenza and hepatitis B vaccination coverage among healthcare workers in Croatian hospitals: a series of cross-sectional surveys, 2006–2011 
BMC Infectious Diseases  2013;13:520.
Background
Healthcare workers (HCWs) are at an increased risk of exposure to and transmission of infectious diseases. Vaccination lowers morbidity and mortality of HCWs and their patients. To assess vaccination coverage for influenza and hepatitis B virus (HBV) among HCWs in Croatian hospitals, we conducted yearly nationwide surveys.
Methods
From 2006 to 2011, all 66 Croatian public hospitals, representing 43–60% of all the HCWs in Croatia, were included. Statistical analysis was performed using the Kruskal–Wallis analysis of variance, Dunn’s multiple comparison analysis and the chi-square test, as appropriate.
Results
The median seasonal influenza vaccination coverage rates in pre-pandemic (2006–2008) seasons were 36%, 25% and 29%, respectively. By occupation, influenza vaccination rates among physicians were 33 ± 21%, 33 ± 22% among graduate nurses, 30±34% among other HCWs, 26 ± 21% among housekeeping and the lowest, 23 ± 17%, among practical nurses (p < 0.01). In 2009–2010 season, seasonal influenza vaccination coverage was 30%, while overall vaccination coverage against pandemic influenza was fewer than 5%. Median vaccination coverage in the post-pandemic seasons of 2010–2011 and 2011–2012 decreased to 15% and 14%, respectively (reduction of 24% and 35%, respectively, p < 0.0001). Meanwhile, the median mandatory HBV vaccination coverage was 98%, albeit with considerable differences according to work setting (range 19–100%) and occupation (range 4–100%).
Conclusions
We found substantial year-on-year variations in seasonal influenza vaccination rates, with reduction in post pandemic influenza seasons. HBV vaccination is satisfactory compared to seasonal influenza vaccination coverage, although substantial variations by occupation and work setting were observed. These findings highlight the need for national strategies that optimize vaccination coverage among HCWs in Croatian hospitals. Further studies are needed to establish the potential role of mandatory vaccination for seasonal influenza.
doi:10.1186/1471-2334-13-520
PMCID: PMC3840606  PMID: 24192278
Influenza; Hepatitis B; Healthcare workers; Vaccination
2.  "Will they just pack up and leave?" – attitudes and intended behaviour of hospital health care workers during an influenza pandemic 
Background
There is a general consensus that another influenza pandemic is inevitable. Although health care workers (HCWs) are essential to the health system response, there are few studies exploring HCW attitudes to pandemic influenza. The aim of this study was to explore HCWs knowledge, attitudes and intended behaviour towards pandemic influenza.
Methods
Cross-sectional investigation of a convenience sample of clinical and non-clinical HCWs from two tertiary-referral teaching hospitals in Sydney, Australia was conducted between June 4 and October 19, 2007. The self-administered questionnaire was distributed to hospital personal from 40 different wards and departments. The main outcome measures were intentions regarding work attendance and quarantine, antiviral use and perceived preparation.
Results
Respondents were categorized into four main groups by occupation: Nursing (47.5%), Medical (26.0%), Allied (15.3%) and Ancillary (11.2%). Our study found that most HCWs perceived pandemic influenza to be very serious (80.9%, n = 873) but less than half were able to correctly define it (43.9%, n = 473). Only 24.8% of respondents believed their department to be prepared for a pandemic, but nonetheless most were willing to work during a pandemic if a patient or colleague had influenza. The main determinants of variation in our study were occupational factors, demographics and health beliefs. Non-clinical staff were significantly most likely to be unsure of their intentions (OR 1.43, p < 0.001). Only 42.5% (n = 459) of respondents considered that neuraminidase inhibitor antiviral medications (oseltamivir/zanamivir) would protect them against pandemic influenza, whereas 77.5% (n = 836) believed that vaccination would be of benefit.
Conclusion
We identified two issues that could undermine the best of pandemic plans – the first, a low level of confidence in antivirals as an effective measure; secondly, that non-clinical workers are an overlooked group whose lack of knowledge and awareness could undermine pandemic plans. Other issues included a high level of confidence in dietary measures to protect against influenza, and a belief among ancillary workers that antibiotics would be protective. All health care worker strategies should include non clinical and ancillary staff to ensure adequate business continuity for hospitals. HCW education, psychosocial support and staff communication could improve knowledge of appropriate pandemic interventions and confidence in antivirals.
doi:10.1186/1472-6963-9-30
PMCID: PMC2661074  PMID: 19216792
3.  Did the pandemic have an impact on influenza vaccination attitude? a survey among health care workers 
Background
Health care workers' (HCWs) influenza vaccination attitude is known to be negative. The H1N1 epidemic had started in mid 2009 and made a peak in October-November in Turkey. A national vaccination campaign began on November 2nd, 2009. Despite the diligent efforts of the Ministry of Health and NGOs, the attitudes of the media and politicians were mostly negative. The aim of this study was to evaluate whether HCWs' vaccination attitudes improved during the pandemic and to assess the related factors.
Methods
This cross-sectional survey was carried out at the largest university hospital of the Aegean Region-Turkey. A self-administered questionnaire with 12 structured questions was applied to 807 HCWs (sample coverage 91.3%) before the onset of the vaccination programme. Their final vaccination status was tracked one week afterwards, using immunization records. Factors influencing vaccination rates were analyzed using ANOVA, t-test, chi-square test and logistic regression.
Results
Among 807 participants, 363 (45.3%) were doctors and 293 (36.6%) nurses. A total of 153 (19.0%) had been vaccinated against seasonal influenza in the 2008-2009 season. Regarding H1N1 vaccination, 143 (17.7%) were willing to be vaccinated vs. 357 (44.2%) unwilling. The number of indecisive HCWs was 307 (38.0%) one week prior to vaccination. Only 53 (11.1%) stated that they would vaccinate their children. Possible side effects (78%, n = 519) and lack of comprehensive field evaluation before marketing (77%, n = 508) were the most common reasons underlying unwillingness or hesitation.
Among the 749 staff whose vaccination status could be tracked, 228 (30.4%) actually received the H1N1 vaccine. Some of the 'decided' staff members had changed their mind one week later. Only 82 (60%) of those willing, 108 (37%) of those indecisive and 38 (12%) of those unwilling were vaccinated.
Indecisive HCWs were significantly younger (p = 0.017). Females, nurses, and HCWs working in surgical departments were more likely to reject vaccination (p < 0.05). Doctors, HCWs working in medical departments, and HCWs previously vaccinated against seasonal influenza were more likely to accept vaccination (p < 0.05). Being younger than 50 and having been vaccinated in the previous season were important predictors of attitude towards pandemic influenza vaccination.
Conclusions
Vaccination rates increased substantially in comparison to the previous influenza season. However, vaccination rates could have been even higher since hesitation to be vaccinated increased dramatically within one week (only 60% of those willing and the minority of those indecisive were finally vaccinated). We speculate that this may be connected with negative media at the time.
doi:10.1186/1471-2334-11-87
PMCID: PMC3084177  PMID: 21473763
4.  Knowledge, attitudes and anxiety towards influenza A/H1N1 vaccination of healthcare workers in Turkey 
BMC Infectious Diseases  2010;10:281.
Background
This study aimed to analyze the factors associated with knowledge and attitudes about influenza A (H1N1) and vaccination, and possible relations of these factors with anxiety among healthcare workers (HCW).
Methods
The study used a cross-sectional descriptive design, and it was carried out between 23 November and 4 December 2009. A total of 300 HCW from two hospitals completed a questionnaire. Data collection tools comprised a questionnaire and the State-Trait Anxiety Inventory (STAI).
Results
Vaccination rate for 2009 pandemic influenza A(H1N1) among HCW was low (12.7%). Most of the respondents believed the vaccine was not safe and protective. Vaccination refusal was mostly related to the vaccine's side effects, disbelief to vaccine's protectiveness, negative news about the vaccine and the perceived negative attitude of the Prime Minister to the vaccine. State anxiety was found to be high in respondents who felt the vaccine was unsafe.
Conclusions
HCW considered the seriousness of the outbreak, their vaccination rate was low. In vaccination campaigns, governments have to aim at providing trust, and media campaigns should be used to reinforce this trust as well. Accurate reporting by the media of the safety and efficacy of influenza vaccines and the importance of vaccines for the public health would likely have a positive influence on vaccine uptake. Uncertain or negative reporting about the vaccine is detrimental to vaccination efforts.
doi:10.1186/1471-2334-10-281
PMCID: PMC3161359  PMID: 20863386
5.  Longitudinal seroepidemiologic study of the 2009 pandemic influenza A (H1N1) infection among health care workers in a children's hospital 
Background
To probe seroepidemiology of the 2009 pandemic influenza A (H1N1) among health care workers (HCWs) in a children's hospital.
Methods
From August 2009 to March 2010, serum samples were drawn from 150 HCWs in a children's hospital in Taipei before the 2009 influenza A (H1N1) pandemic, before H1N1 vaccination, and after the pandemic. HCWs who had come into direct contact with 2009 influenza A (H1N1) patients or their clinical respiratory samples during their daily work were designated as a high-risk group. Antibody levels were determined by hemagglutination inhibition (HAI) assay. A four-fold or greater increase in HAI titers between any successive paired sera was defined as seroconversion, and factors associated with seroconversion were analyzed.
Results
Among the 150 HCWs, 18 (12.0%) showed either virological or serological evidence of 2009 pandemic influenza A (H1N1) infection. Of the 90 unvaccinated HCWs, baseline and post-pandemic seroprotective rates were 5.6% and 20.0%. Seroconversion rates among unvaccinated HCWs were 14.4% (13/90), 22.5% (9/40), and 8.0% (4/50) for total, high-risk group, and low-risk group, respectively. Multivariate analysis revealed being in the high-risk group is an independent risk factor associated with seroconversion.
Conclusion
The infection rate of 2009 pandemic influenza A (H1N1) in HCWs was moderate and not higher than that for the general population. The majority of unvaccinated HCWs remained susceptible. Direct contact of influenza patients and their respiratory samples increased the risk of infection.
doi:10.1186/1471-2334-12-89
PMCID: PMC3364885  PMID: 22498010
Influenza; Pandemic; H1N1; Health care workers; Children
6.  Healthcare workers and health care-associated infections: knowledge, attitudes, and behavior in emergency departments in Italy 
Background
This survey assessed knowledge, attitudes, and compliance regarding standard precautions about health care-associated infections (HAIs) and the associated determinants among healthcare workers (HCWs) in emergency departments in Italy.
Methods
An anonymous questionnaire, self-administered by all HCWs in eight randomly selected non-academic acute general public hospitals, comprised questions on demographic and occupational characteristics; knowledge about the risks of acquiring and/or transmitting HAIs from/to a patient and standard precautions; attitudes toward guidelines and risk perceived of acquiring a HAI; practice of standard precautions; and sources of information.
Results
HCWs who know the risk of acquiring Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) from a patient were in practice from less years, worked fewer hours per week, knew that a HCW can transmit HCV and HIV to a patient, knew that HCV and HIV infections can be serious, and have received information from educational courses and scientific journals. Those who know that gloves, mask, protective eyewear, and hands hygiene after removing gloves are control measures were nurses, provided care to fewer patients, knew that HCWs' hands are vehicle for transmission of nosocomial pathogens, did not know that a HCW can transmit HCV and HIV to a patient, and have received information from educational courses and scientific journals. Being a nurse, knowing that HCWs' hands are vehicle for transmission of nosocomial pathogens, obtaining information from educational courses and scientific journals, and needing information were associated with a higher perceived risk of acquiring a HAI. HCWs who often or always used gloves and performed hands hygiene measures after removing gloves were nurses, provided care to fewer patients, and knew that hands hygiene after removing gloves was a control measure.
Conclusions
HCWs have high knowledge, positive attitudes, but low compliance concerning standard precautions. Nurses had higher knowledge, perceived risk, and appropriate HAIs' control measures than physicians and HCWs answered correctly and used appropriately control measures if have received information from educational courses and scientific journals.
doi:10.1186/1471-2334-10-35
PMCID: PMC2848042  PMID: 20178573
7.  Knowledge, attitudes and behaviour of hospital health-care workers regarding influenza A/H1N1: a cross sectional survey 
BMC Infectious Diseases  2014;14:208.
Background
To assess the knowledge, the attitudes, and the behaviour towards influenza A/H1N1 and the vaccination among health-care workers (HCWs).
Methods
A sample of HCWs was selected from a random sample of non-teaching public hospitals, located in the cities of Naples and Avellino (Italy), received a self-administered anonymous questionnaire including questions about socio-demographic characteristics, knowledge on modes of transmission and preventative measures, attitudes and behaviour relating to influenza A/H1N1.
Results
Only 36.1% correctly knew the main modes of transmission, and that HCWs are a risk category and this level of knowledge was significantly higher in HCWs having received information through scientific journals. A higher perceived risk of contracting influenza A/H1N1 has been observed in the HCWs more knowledgeable, in those considering influenza A/H1N1 a serious disease, and in those working in surgical wards. Only 16.7% have received the influenza A/H1N1 vaccination and HCWs with more fear of contracting influenza A/H1N1, those considering vaccine more useful and less dangerous were more likely to receive vaccine.
Conclusions
Education and communication strategies for improving the level of knowledge and for the immunization uptake regarding influenza A/H1N1 HCWs are strongly needed.
doi:10.1186/1471-2334-14-208
PMCID: PMC4021506  PMID: 24739890
Attitudes; Behaviour; Health-care workers; Influenza A/H1N1; Knowledge
8.  Personal Decision-Making Criteria Related to Seasonal and Pandemic A(H1N1) Influenza-Vaccination Acceptance among French Healthcare Workers 
PLoS ONE  2012;7(7):e38646.
Background
Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination.
Methods
In June–July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs' SIV and PIV profiles were analyzed using the classification-and-regression–tree method.
Results
Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV.
Conclusions
Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.
doi:10.1371/journal.pone.0038646
PMCID: PMC3407215  PMID: 22848342
9.  Protecting patients, protecting healthcare workers: a review of the role of influenza vaccination 
International Nursing Review  2011;59(2):161-167.
MUSIC T. (2012) A review of the role the role of influenza vaccination in protecting patients, protecting healthcare workers the role of influenza vaccination. International Nursing Review59, 161–167
Aim:
Many health authorities recommend routine influenza vaccination for healthcare workers (HCWs), and during the 2009 A (H1N1) pandemic, the World Health Organization (WHO) recommended immunization of all HCWs worldwide. As this remains an important area of policy debate, this paper examines the case for vaccination, the role of local guidelines, barriers to immunization and initiatives to increase uptake.
Background:
Seasonal influenza is a major threat to public health, causing up to 1 million deaths annually. Extensive evidence supports the vaccination of priority groups, including HCWs. Immunization protects HCWs themselves, and their vulnerable patients from nosocomial influenza infections. In addition, influenza can disrupt health services and impact healthcare organizations financially. Immunization can reduce staff absences, offer cost savings and provide economic benefits.
Methods:
This paper reviews official immunization recommendations and HCW vaccination studies, including a recent International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) survey of 26 countries from each region of the world.
Results:
HCW immunization is widely recommended and supported by the WHO. In the IFPMA study, 88% of countries recommended HCW vaccination, and 61% supported this financially (with no correlation to country development status). Overall, coverage can be improved, and research shows that uptake may be impacted by lack of conveniently available vaccines and misconceptions regarding vaccine safety/efficacy and influenza risk.
Conclusions:
Many countries recommend HCW vaccination against influenza. In recent years, there has been an increased uptake rate among HCWs in some countries, but not in others. Several initiatives can increase coverage, including education, easy access to free vaccines and the use of formal declination forms. The case for HCW vaccination is clear, and in an effort to further accelerate uptake as a patient safety measure, an increasing number of healthcare organizations, particularly in the USA, are implementing mandatory immunization policies, similar to other obligatory hygiene measures. However, it would be desirable if similar high vaccination uptake rates could be achieved through voluntary procedures.
doi:10.1111/j.1466-7657.2011.00961.x
PMCID: PMC3418836  PMID: 22591085
Coverage; Education; Guideline; Influenza; Policy; Recommendation; Reimbursement; Seasonal; Vaccine
10.  Influenza vaccination coverage of healthcare workers and residents and their determinants in nursing homes for elderly people in France: a cross-sectional survey 
BMC Public Health  2010;10:159.
Background
Nursing home residents bear a substantial burden of influenza morbidity and mortality. Vaccination of residents and healthcare workers (HCWs) is the main strategy for prevention. Despite recommendations, influenza vaccination coverage among HCWs remains generally low.
Methods
During the 2007-2008 influenza season, we conducted a nationwide survey to estimate influenza vaccination coverage of HCWs and residents in nursing homes for elderly people in France and to identify determinants of vaccination rates. Multivariate analysis were performed with a negative binomial regression.
Results
Influenza vaccination coverage rates were 33.6% (95% CI: 31.9-35.4) for HCWs and 91% (95% CI: 90-92) for residents. Influenza vaccination uptake of HCWs varied by occupational category. Higher vaccination coverage was found in private elderly care residences, when free vaccination was offered (RR: 1.89, 1.35-2.64), in small nursing homes (RR: 1.54, 1.31-1.81) and when training sessions and staff meetings on influenza were organized (RR: 1.20, 1.11-1.29). The analysis by occupational category showed that some determinants were shared by all categories of professionals (type of nursing homes, organization of training and staff meetings on influenza). Higher influenza vaccination coverage was found when free vaccination was offered to recreational, cleaning, administrative staff, nurses and nurse assistants, but not for physicians.
Conclusions
This nationwide study assessed for the first time the rate of influenza vaccination among residents and HCWs in nursing homes for elderly in France. Better communication on the current recommendations regarding influenza vaccination is needed to increase compliance of HCWs. Vaccination programmes should include free vaccination and education campaigns targeting in priority nurses and nurse assistants.
doi:10.1186/1471-2458-10-159
PMCID: PMC2850345  PMID: 20338028
11.  Protecting health care workers: a pandemic simulation based on Allegheny County 
Background and Objectives
The Advisory Committee on Immunization Practices has identified health care workers (HCWs) as a priority group to receive influenza vaccine. Although the importance of HCW to the health care system is well understood, the potential role of HCW in transmission during an epidemic has not been clearly established.
Methods
Using a standard SIR (Susceptible–Infected–Recovered) framework similar to previously developed pandemic models, we developed an agent-based model (ABM) of Allegheny County, PA, that incorporates the key health care system features to simulate the spread of an influenza epidemic and its effect on hospital-based HCWs.
Findings
Our simulation runs found the secondary attack rate among unprotected HCWs to be approximately 60% higher (54·3%) as that of all adults (34·1%), which would result in substantial absenteeism and additional risk to HCW families. Understanding how a pandemic may affect HCWs, who must be available to treat infected patients as well as patients with other medical conditions, is crucial to policy makers’ and hospital administrators’ preparedness planning.
doi:10.1111/j.1750-2659.2009.00122.x
PMCID: PMC2894576  PMID: 20167046
Computer simulation; infectious disease transmission; human influenza; professional to patient; agent-based model; pandemic
12.  A Surveillance System to Reduce Transmission of Pandemic H1N1 (2009) Influenza in a 2600-Bed Medical Center 
PLoS ONE  2012;7(3):e32731.
Background
Concerns have been raised about how the transmission of emerging infectious diseases from patients to healthcare workers (HCWs) and vice versa could be recognized and prevented in a timely manner. An effective strategy to block transmission of pandemic H1N1 (2009) influenza in HCWs is important.
Methodology/Principal Findings
An infection control program was implemented to survey and prevent nosocomial outbreaks of H1N1 (2009) influenza at a 2,600-bed, tertiary-care academic hospital. In total, 4,963 employees at Kaohsiung Chang Gung Memorial Hospital recorded their temperature and received online education on control practices for influenza infections. Administration records provided vaccination records and occupational characteristics of all HCWs. Early recognition of a pandemic H1N1 (2009) influenza case was followed by a semi-structured questionnaire to analyze possible routes of patient contact, household contact, or unspecified contact. Surveillance spanned August 1, 2009 to January 31, 2010; 51 HCWs were confirmed to have novel H1N1 (2009) influenza by quantitative real-time reverse transcription polymerase chain reaction. Prevalence of patient contact, household contact, or unspecified contact infection was 13.7% (7/51), 13.7% (7/51), and 72.5% (37/51), respectively. The prevalence of the novel H1N1 infection was significantly lower among vaccinated HCWs than among unvaccinated HCWs (p<0.001). Higher viral loads in throat swabs were found in HCWs with patient and household contact infection than in those with unspecified contact infection (4.15 vs. 3.53 copies/mL, log10, p = 0.035).
Conclusion
A surveillance system with daily temperature recordings and online education for HCWs is important for a low attack rate of H1N1 (2009) influenza transmission before H1N1 (2009) influenza vaccination is available, and the attack rate is further decreased after mass vaccination. Unspecified contact infection rates were significantly higher than that of patient contact and household contact infection, highlighting the need for public education of influenza transmission in addition to hospital infection control.
doi:10.1371/journal.pone.0032731
PMCID: PMC3302803  PMID: 22427871
13.  Long-Term Immunogenicity of the Pandemic Influenza A/H1N1 2009 Vaccine among Health Care Workers: Influence of Prior Seasonal Influenza Vaccination 
Health care workers (HCWs) are at great risk of influenza infection and transmission. Vaccination for seasonal influenza is routinely recommended, but this strategy should be reconsidered in a pandemic situation. Between October 2009 and September 2010, a multicenter study was conducted to assess the long-term immunogenicity of the A/H1N1 2009 monovalent influenza vaccine among HCWs compared to non-health care workers (NHCWs). The influence of prior seasonal influenza vaccination was also assessed with respect to the immunogenicity of pandemic H1N1 influenza vaccine. Serum hemagglutinin inhibition titers were determined prevaccination and then at 1, 6, and 10 months after vaccination. Of the 360 enrolled HCW subjects, 289 participated in the study up to 10 months after H1N1 monovalent influenza vaccination, while 60 of 65 NHCW subjects were followed up. Seroprotection rates, seroconversion rates, and geometric mean titer (GMT) ratios fulfilled the European Union's licensure criteria for influenza A/California/7/2009 (H1N1) at 1 month after vaccination in both the HCWs and NHCWs, without any significant difference. At 6 months after vaccination, the seroprotection rate was more significantly lowered among the NHCWs than among the HCWs (P < 0.01). Overall, postvaccination (1, 6, and 10 months after vaccination) GMTs for A/California/7/2009 (H1N1) were significantly lower among the seasonal influenza vaccine recipients than among the nonrecipients (P < 0.05). In conclusion, HCWs should be encouraged to receive an annual influenza vaccination, considering the risk of repeated exposure. However, prior reception of seasonal influenza vaccine showed a negative influence on immunogenicity for the pandemic A/H1N1 2009 influenza vaccine.
doi:10.1128/CVI.00725-12
PMCID: PMC3623406  PMID: 23365206
14.  Acceptance of a Vaccine Against Novel Influenza A (H1N1) Virus Among Health Care Workers in Two Major Cities in Mexico 
Archives of medical research  2009;40(8):705-711.
Background and Aims
Further cases of novel influenza A (H1N1) outbreak are expected in the coming months. Vaccination has been proven to be essential to control a pandemic of influenza; therefore, considerable efforts and resources have been devoted to develop a vaccine against the influenza A (H1N1) virus. With the current availability of the vaccine, it will be important to immunize as many people as possible. However, previous data with seasonal influenza vaccines have shown that there are multiple barriers related to perceptions and attitudes of the population that influence vaccine use. The aim of the study was to evaluate the acceptance of a newly developed vaccine against pandemic (H1N1) 2009 influenza A among healthcare workers (HCW) in Mexico.
Methods
We conducted a cross-sectional study among HCW in three hospitals in the two largest cities in Mexico—Mexico City and Guadalajara—between June and September 2009.
Results
A total of 1097 HCW participated in the survey. Overall, 80% (n = 880) intended to accept the H1N1 pandemic vaccine and 71.6% (n = 786) reported they would recommend the vaccine to their patients. Doctors were more likely to accept and recommend the vaccine than nurses. HCWs who intend to be immunized will be more likely to do so if they know that the vaccine is safe and effective.
Conclusions
Knowledge of the willingness to accept the vaccine can be used to plan strategies that will effectively respond to the needs of the population studied, reducing the health and economic impact of novel influenza A (H1N1) virus.
doi:10.1016/j.arcmed.2010.01.004
PMCID: PMC2854164  PMID: 20304260
Vaccine acceptance; Influenza A (H1N1) virus; Health care workers
15.  Long-Term Persistence of Seroprotection by Hepatitis B Vaccination in Healthcare Workers of Southern Italy 
Hepatitis Monthly  2012;12(9):e6025.
Background
The impact of hepatitis B virus (HBV) vaccination campaigns on HBV epidemiology needs to be evaluated, in order to assess the long-term immunity offered by vaccines against HBV.
Objectives
To evaluate the current status of anti-HBV vaccine coverage among healthcare workers (HCWs) in Southern Italy, and to determine the long-term persistence of antibodies to hepatitis B surface antigens (anti-HBs) in such a cohort of subjects.
Patients and Methods
A longitudinal, retrospective seroepidemiological survey was conducted among 451 HCWs, who were working at or visiting, the Occupational Health Department of a city hospital, in Catania, Italy, between January 1976 and December 2010.
Results
At the 30-year follow-up (mean follow-up 10.15 ± 5.96 years, range 0.74-30), 261 HCWs had detectable anti-HBs titers indicating a persistence of seroprotection of 89.4% (out of 292 anti-HBs positive results, three months after vaccination). An inadequate vaccination schedule was the strongest predictor of antibody loss during follow-up (OR = 8.37 95% CI: 5.41-12.95, P < 0.001). A Kaplan-Maier survival curve revealed that the persistence of anti-HBs 30 years after vaccination, was 92.2% for high responders, while it was only 27.3% for low responders (P = 0.001).
Conclusions
A good level of seroprotection persisted in 57.9% of the subjects after 30 years. Factors related to this immunization status confirmed the importance of vaccinating HCWs early in their careers and ensuring an adequate vaccination schedule. However, with particular reference to the low rate of hepatitis B vaccine coverage among HCWs in Southern Italy, the implementation of a new educational intervention as part of an active vaccination program is needed.
doi:10.5812/hepatmon.6025
PMCID: PMC3475028  PMID: 23087756
Hepatitis B Virus; Vaccines; Health Personnel; Vaccination
16.  Vaccination coverage for seasonal influenza among residents and health care workers in Norwegian nursing homes during the 2012/13 season, a cross-sectional study 
BMC Public Health  2014;14:434.
Background
WHO has set a goal of 75% vaccination coverage (VC) for seasonal influenza for residents and also recommends immunization for all healthcare workers (HCWs) in nursing homes (NHs). We conducted a cross-sectional study to estimate the VC for seasonal influenza vaccination in Norwegian NHs in 2012/2013 since the VC in NHs and HCWs is unknown.
Methods
We gathered information from NHs concerning VC for residents and HCWs, and vaccination costs for HCWs, using a web-based questionnaire. We calculated VC among NH residents by dividing the number of residents vaccinated by the total number of residents for each NH. VC among HCWs was similarly calculated by dividing the number of HCWs vaccinated by the total number of HCWs for each NH. The association between VC and possible demographic variables were explored.
Results
Of 910 NHs, 354 (38.9%) responded. Median VC per NH was 71.7% (range 0-100) among residents and 0% (range 0-100) among HCWs, with 214 (60%) NHs reporting that none of their HCWs was vaccinated. Median VC for HCWs in NHs with an annual vaccination campaign was 0% (range 0-53), compared to when they did not have an annual vaccination campaign 0% (range 0-12); the distributions in the two groups differed significantly (Mann–Whitney U, P = 0.006 two tailed).
Conclusion
Median influenza VC in Norwegian NHs was marginally lower than recommended among residents and exceptionally low among HCWs. The VC in HCWs was significantly higher when NHs had an annual vaccination campaign. We recommend that NHs implement measures to increase VC among residents and HCWs, including vaccination campaigns and studies to identify potential barriers to vaccination.
doi:10.1186/1471-2458-14-434
PMCID: PMC4049507  PMID: 24885662
17.  BRIEF REPORT: Influenza Vaccination and Health Care Workers in the United States 
OBJECTIVE
To determine influenza vaccination rates among U.S. health care workers (HCWs) by demographic and occupational categories.
DESIGN AND PARTICIPANTS
We analyzed data from the 2000 National Health Interview Survey (NHIS). Weighted multivariable analyses were used to evaluate the association between HCW occupation and other variables potentially related to receipt of influenza vaccination. HCWs were categorized based on standard occupational classifications as health-diagnosing professions, health-assessing professions, health aides, health technicians; or health administrators.
MAIN INDEPENDENT VARIABLES
Demographic characteristics and occupation category.
MAIN OUTCOME VARIABLES
Receipt of influenza vaccination within 12 months of survey.
ANALYSIS
Descriptive statistics and weighted multivariable logistic regression.
RESULTS
There were 1,651 HCWs in the final sample. The overall influenza vaccination rate for HCWs was 38%. After weighted multivariable analyses, HCWs who were under 50 (odds ratio [OR] 0.67%, 95% confidence interval [CI]: 0.50 to 0.89, compared with HCWs 50 to 64), black (OR 0.57 95% CI: 0.42, 0.78, compared with white HCWs), or were health aides (OR 0.73%, 95% CI: 0.51, 1.04, compared with health care administrators and administrative support staff) had lower odds of having been vaccinated against influenza.
CONCLUSIONS
The overall influenza vaccination rate among HCWs in the United States is low. Workers who are under 50, black, or health aides have the lowest rates of vaccinations. Interventions seeking to improve HCW vaccination rates may need to target these specific subgroups.
doi:10.1111/j.1525-1497.2006.00325.x
PMCID: PMC1484661  PMID: 16606378
Influenza vaccinations; health care workers; National Health Interview Survey; nosocomial infection; employee health
18.  Fighting Misconceptions to Improve Compliance with Influenza Vaccination among Health Care Workers: An Educational Project 
PLoS ONE  2012;7(2):e30670.
The compliance with influenza vaccination is poor among health care workers (HCWs) due to misconceptions about safety and effectiveness of influenza vaccine. We proposed an educational prospective study to demonstrate to HCWs that influenza vaccine is safe and that other respiratory viruses (RV) are the cause of respiratory symptoms in the months following influenza vaccination. 398 HCWs were surveyed for adverse events (AE) occurring within 48 h of vaccination. AE were reported by 30% of the HCWs. No severe AE was observed. A subset of 337 HCWs was followed up during four months, twice a week, for the detection of respiratory symptoms. RV was diagnosed by direct immunofluorescent assay (DFA) and real time PCR in symptomatic HCWs. Influenza A was detected in five episodes of respiratory symptoms (5.3%) and other RV in 26 (27.9%) episodes. The incidence density of influenza and other RV was 4.3 and 10.8 episodes per 100 HCW-month, respectively. The educational nature of the present study may persuade HCWs to develop a more positive attitude to influenza vaccination.
doi:10.1371/journal.pone.0030670
PMCID: PMC3273463  PMID: 22328920
19.  A Time Off Incentive Was Not Associated with Influenza Vaccination Acceptance among Healthcare Workers 
Objectives. The national influenza vaccination rate among healthcare workers (HCWs) remains low despite clear benefits to patients, coworkers, and families. We sought to evaluate formally the effect of a one-hour time off incentive on attitudes towards influenza vaccination during the 2011-2012 influenza season. Methods. All HCWs at the Philadelphia Veterans Affairs (VA) Medical Center were invited to complete an anonymous web-based survey. We described respondents' characteristics and attitudes toward influenza vaccination and determined the relationship of specific attitudes with respondents' acceptance of influenza vaccination, using a 5-point Likert scale. Results. We analyzed survey responses from 154 HCWs employed at the Philadelphia VA Medical Center, with a response rate of 8%. Among 121 respondents who reported receiving influenza vaccination, 34 (28%, 95% CI 20–37%) reported agreement with the statement that the time off incentive made a difference in their decision to accept influenza vaccination. Conclusions. Our study provides evidence that modest incentives such as one-hour paid time off will be unlikely to promote influenza vaccination rates within medical facilities. More potent interventions that include mandatory vaccination combined with penalties for noncompliance will likely provide the only means to achieve near-universal influenza vaccination among HCWs.
doi:10.1155/2013/209491
PMCID: PMC3710596  PMID: 23878733
20.  INFLUENZA VACCINATION IN HEALTHCARE WORKERS: 10-YEAR EXPERIENCE OF A LARGE HEALTHCARE ORGANIZATION 
Objective
To describe the results of different measures implemented to improve compliance with the healthcare worker (HCW) influenza immunization program at BJC HealthCare between 1997 and 2007.
Design
Descriptive retrospective study.
Setting
BJC HealthCare, a 13-hospital nonprofit healthcare organization in the Midwest.
Methods
Review and analysis of HCW influenza vaccination data from all BJC HealthCare Occupational Health Services and hospitals between 1997 and 2007. Occupational health staff, infection prevention personnel and key influenza vaccine campaign leaders were also interviewed regarding implementation measures during the study years.
Results
At the end of 2007, BJC HealthCare had approximately 26,000 employees. Using multiple progressive interventions, influenza vaccination rates among BJC employees increased from 45% in 1997 to 71.9% in 2007 (p<0.001). The influenza vaccination rate in 2007 was significantly higher than in 2006, 71.9% versus 54.2% (p<0.001). Five hospitals had influenza vaccination rates over the target goal of 80% in 2007. The most successful interventions were adding influenza vaccination rates to the incented quality scorecard and declination statements, both implemented in 2007. The most important barriers identified in the interviews related to HCWs’ misconceptions about influenza vaccination and a perceived lack of leadership support.
Conclusions
Influenza vaccination rates in HCWs significantly improved with multiple interventions over the years. However, the BJC HealthCare influenza vaccination target of 80% was not attained at all hospitals with these measures. More aggressive interventions such as implementing mandatory influenza vaccination policies are needed to achieve higher vaccination rates.
doi:10.1086/650449
PMCID: PMC3919446  PMID: 20055666
21.  Planning and process evaluation of a multi-faceted influenza vaccination implementation strategy for health care workers in acute health care settings 
BMC Infectious Diseases  2013;13:235.
Background
Influenza transmitted by health care workers (HCWs) is a potential threat to frail patients in acute health care settings. Therefore, immunizing HCWs against influenza should receive high priority. Despite recommendations of the World Health Organization, vaccine coverage of HCWs remains low in all European countries. This study explores the use of intervention strategies and methods to improve influenza vaccination rates among HCWs in an acute care setting.
Methods
The Intervention Mapping (IM) method was used to systematically develop and implement an intervention strategy aimed at changing influenza vaccination behaviour among HCWs in Dutch University Medical Centres (UMCs). Carried out during the influenza seasons 2009/2010 and 2010/2011, the interventions were then qualitatively and quantitatively evaluated by way of feedback from participating UMCs and the completion of a web-based staff questionnaire in the following spring of each season.
Results
The IM method resulted in the development of a transparent influenza vaccination intervention implementation strategy. The intervention strategy was offered to six Dutch UMCs in a randomized in a clustered Randomized Controlled Trial (RCT), where three UMCs were chosen for intervention, and three UMCs acted as controls. A further two UMCs elected to have the intervention. The qualitative process evaluation showed that HCWs at four of the five intervention UMCs were responsive to the majority of the 11 relevant behavioural determinants resulting from the needs assessment in their intervention strategy compared with only one of three control UMCs. The quantitative evaluation among a sample of HCWs revealed that of all the developed communication materials, HCWs reported the posters as the most noticeable.
Conclusions
Our study demonstrates that it is possible to develop a structured implementation strategy for increasing the rate of influenza vaccination by HCWs in acute health care settings. The evaluation also showed that it is impossible to expose all HCWs to all intervention methods (which would have been the best case scenario). Further study is needed to (1) improve HCW exposure to intervention methods; (2) determine the effect of such interventions on vaccine uptake among HCWs; and (3) assess the impact on clinical outcomes among patients when such interventions are enacted.
doi:10.1186/1471-2334-13-235
PMCID: PMC3680164  PMID: 23701921
Influenza vaccination; Health care workers; Intervention mapping; Intervention implementation; Acute health care
22.  Increased risk of tuberculosis in health care workers: a retrospective survey at a teaching hospital in Istanbul, Turkey 
Background
Tuberculosis (TB) is an established occupational disease affecting health care workers (HCWs). Determining the risk of TB among HCWs is important to enable authorites to take preventative measures in health care facilities and protect HCWs. This study was designed to assess the incidence of TB in a teaching hospital in Istanbul, Turkey. This study is retrospective study of health records of HCWs in our hospital from 1991 to 2000.
Results
The mean workforce of the hospital was 3359 + 33.2 between 1991 and 2000. There were 31 cases (15 male) meeting the diagnostic criteria for TB, comprising eight doctors, one nurse and 22 other health professionals. Mean incidence of TB was 96 per 100,000 for all HCWs (relative risk: 2.71), 79 per 100,000 for doctors (relative risk: 2.2), 14 per 100,000 for nurses and 121 per 100,000 (relative risk: 3.4) for other professionals. The mean incidence of TB in Turkey between 1991 and 2000 was 35.4 per 100,000. Incidence of TB was similar in the Departments of Chest Diseases and Clinical Medicine but there were no TB cases in the Basic Science and Managerial Departments.
Conclusion
HCWs in Turkey who work in clinics have an increased risk for TB. Post-graduate education and prevention programs reduce the risk of TB. Control programs to prevent nosocomial transmission of TB should be established in hospitals to reduce risk for HCWs.
doi:10.1186/1471-2334-2-14
PMCID: PMC122064  PMID: 12144709
23.  Determinants of influenza vaccination uptake among Italian healthcare workers 
We analyzed seasonal influenza vaccination coverage among the Italian healthcare workers (HCW) in order to identify socio-demographic and clinical determinants of vaccination.
We used data from the survey “Health and health care use in Italy,” which comprised interviews of 5,336 HCWs For each respondent, information on socioeconomic, health conditions, self-perceived health and smoking status were obtained. After bivariate analysis, we used multilevel regression models to assess determinants of immunization. Overall 20.8% of HCWs (95%CI 19.7–21.9) reported being vaccinated against seasonal influenza.
After controlling for potential confounders, multilevel regression revealed that older workers have a higher likelihood of vaccine uptake (OR = 6.07; 95% CI 4.72–7.79). Conversely, higher education was associated with lower vaccine uptake (OR = 0.65; 95% IC 0.50–0.83). Those suffering from diabetes (OR = 2.07; 95% CI 1.19–1.69), COPD (OR = 1.95; 95% CI 1.31–2.89) and cardiovascular diseases (OR = 1.48 95% CI 1.11–1.96) were more likely to be vaccinated. Likewise, smokers, or former smokers receive more frequently the vaccination (OR = 1.40; 95% CI 1.15–1.70; OR = 1.54; 95% CI 1.24–1.91, respectively) compared with never-smokers as well as those HCWs reporting fair or poor perceived health status (ORs of 1.68, 95% CI 1.30–2.18).
Vaccine coverage among HCWs in Italy remains low, especially among those with no comorbidities and being younger than 44 y old. This behavior not only raises questions regarding healthcare organization, infection control in healthcare settings and clinical costs, but also brings up ethical issues concerning physicians who seem not to be very concerned about the impact of the flu on themselves, as well as on their patients. Influenza vaccination campaigns will only be effective if HCWs understand their role in influenza transmission and prevention, and realize the importance of vaccination as a preventive measure
doi:10.4161/hv.22997
PMCID: PMC3903913  PMID: 24064543
administration and dosage; attitude of health personnel; health behavior; human prevention and control; influenza; influenza vaccines; socioeconomic factors
24.  Barriers to pandemic influenza vaccination and uptake of seasonal influenza vaccine in the post-pandemic season in Germany 
BMC Public Health  2012;12:938.
Background
In Germany, annual vaccination against seasonal influenza is recommended for certain target groups (e.g. persons aged ≥60 years, chronically ill persons, healthcare workers (HCW)). In season 2009/10, vaccination against pandemic influenza A(H1N1)pdm09, which was controversially discussed in the public, was recommended for the whole population. The objectives of this study were to assess vaccination coverage for seasonal (seasons 2008/09-2010/11) and pandemic influenza (season 2009/10), to identify predictors of and barriers to pandemic vaccine uptake and whether the controversial discussions on pandemic vaccination has had a negative impact on seasonal influenza vaccine uptake in Germany.
Methods
We analysed data from the ‘German Health Update’ (GEDA10) telephone survey (n=22,050) and a smaller GEDA10-follow-up survey (n=2,493), which were both representative of the general population aged ≥18 years living in Germany.
Results
Overall only 8.8% of the adult population in Germany received a vaccination against pandemic influenza. High socioeconomic status, having received a seasonal influenza shot in the previous season, and belonging to a target group for seasonal influenza vaccination were independently associated with the uptake of pandemic vaccines. The main reasons for not receiving a pandemic vaccination were ‘fear of side effects’ and the opinion that ‘vaccination was not necessary’. Seasonal influenza vaccine uptake in the pre-pandemic season 2008/09 was 52.8% among persons aged ≥60 years; 30.5% among HCW, and 43.3% among chronically ill persons. A decrease in vaccination coverage was observed across all target groups in the first post-pandemic season 2010/11 (50.6%, 25.8%, and 41.0% vaccination coverage, respectively).
Conclusions
Seasonal influenza vaccination coverage in Germany remains in all target groups below 75%, which is a declared goal of the European Union. Our results suggest that controversial public discussions about safety and the benefits of pandemic influenza vaccination may have contributed to both a very low uptake of pandemic vaccines and a decreased uptake of seasonal influenza vaccines in the first post-pandemic season. In the upcoming years, the uptake of seasonal influenza vaccines should be carefully monitored in all target groups to identify if this trend continues and to guide public health authorities in developing more effective vaccination and communication strategies for seasonal influenza vaccination.
doi:10.1186/1471-2458-12-938
PMCID: PMC3527143  PMID: 23113995
Vaccination; Influenza; Coverage; Pandemic; Germany
25.  Influenza Vaccination: Healthcare Workers Attitude in Three Middle East Countries 
Background: Healthcare workers (HCWs) pose a potential risk of transmitting communicable diseases in the hospital settings where they usually work. This study aims to determine the current influenza vaccination rates among HCWs in three Middle East countries namely United Arab Emirates (UAE), Kuwait and Oman, and also to identify the different variables associated with the noncompliance of HCWs to the recommendations of the Advisory Committee on Immunization Practices (ACIP) set in those countries. Methods: 1500 questionnaires were distributed to health care workers in the three countries during the period of July-October 2009. Results: Among 993 respondents, the vaccination rate was 24.7%, 67.2% and 46.4% in UAE, Kuwait and Oman, respectively. The different motivating factors that influenced the health care workers to take the vaccine was assessed and found that the most common factor that influenced their decision to take the vaccine was for their self protection (59%). On the other hand, the most common reason that discouraged HCWs to take the vaccine was “lack of time” as reported by 31.8% of the respondents. Other reasons for not taking the vaccine were unawareness of vaccine availability (29.4%), unavailability of vaccine (25.4%), doubts about vaccine efficacy (24.9%), lack of information about importance (20.1%) and concerns about its side effects (17.3%). Conclusions: influenza immunization by healthcare workers in the studied countries was suboptimal which could be improved by setting different interventions and educational programs to increase vaccination acceptance among HCWs.
PMCID: PMC2948215  PMID: 20922053
Influenza; healthcare workers; vaccination

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