Hepatitis B vaccination coverage levels among health care workers in Greek Military Hospitals.

Balkan Military Medical Review 12, 133-142 (2009) BALKAN Military Medical REVIEW Original Article Hepatitis B vaccination coverage levels among health care workers in Greek Military Hospitals. Dimitris Tsoulas 1, Eleni Apostolopoulou 2 Military Nursing Academy 1 and University of Athens, Faculty of Nursing 2, Athens, Greece Abstract: Routine hepatitis B virus vaccination has been recommended to Health Care Workers since early '90s because of their occupational exposure to blood and body fluids. We conducted a prospective cross sectional survey to obtain an estimate of hepatitis B vaccination coverage rate among nursing personnel and to establish factors associated with hepatitis B vaccination coverage levels. The study took place, at a representative sample of 245 nurses working in 7 Greek military hospitals using self-administrated questionnaires. For data analysis we used univariate and multivariate logistic regression. The self reported hepatitis B vaccination rate among nurses was 75,5%. The coverage level was higher among registered nurses than nurse aids (p<0,001). Other socio-demographic factors associated with higher odds of hepatitis B vaccination were age under 34 years old (p<0,001) and less than 12 years in service (p<0,001). Several attitudes and beliefs were also established with positive correlation of hepatitis B vaccine acceptance; (i) compliance to recommended vaccinations for health care workers, (ii) knowledge about hepatitis B vaccine issues and (iii) belief that hepatitis B infection is a major occupational threat. The study showed a satisfactory frequency of hepatitis B vaccination among nurses working in Greek military hospitals. Nevertheless, further efforts are necessary to increase compliance and hospitals administrations may improve vaccination coverage by developing targeted vaccination programs directed at non-vaccinated Health Care Workers over 34 years old who has potential occupational exposure to blood and body fluids. Keywords: Coverage, Health Care Workers, Hepatitis B, Protection, Prophylaxis, Vaccination. Hepatitis B constitutes a major public health problem globally. There are more than 350 million carriers of Hepatitis B Virus (HBV) throughout the world [1]. Moreover occupational exposure to HBV is a well recognized risk for health care workers (HCWs) [2,3]. Occupational exposures that may result in HBV transmission include percutaneous injury (e.g., needle-stick and other sharp injuries) and contact of mucous membrane (e.g., accidental splashes on eyes, nose, or mouth) or non-intact skin (cutaneous scratches, skin lesions, or burns) with blood or other potentially infectious body fluids [4]. The risk of acquiring infection following a single atrisk exposure ranges from 6%-30% [5]. The high contagiousness of HBV coupled with its ability to resist even for months in the external environment under appropriate conditions explain why this virus constitutes such an occupational threat for HCWs. However prevalence of HBV markers in HCWs is not uniform in all countries, prevalence of infection in the general population has comparable values [6]. According to the prevalence of HBV chronic carriers, regions are differentiating to high (>8%), median (2-8%) and low (<2%) endemicity [7]. Although prevalence of HBV carriers appears to decrease last years, Correspondence to:d. Tsoulas, RN, e-mail: dtsoulas@ath.forthnet.gr

134 prevalence divagates from one region to another and seems to be higher in Northern Greece and Thrake. Indeed in certain populations prevalence of HBV chronic carriers hurdles: 22,5% in refugees in Ioannina, 15% in Greek muslims of Thrake, 8% in Roms [8]. In 1991, the US Occupational Safety and Health Administration issued a regulation requiring employers to offer hepatitis B vaccination free of charge to all employees with reasonably anticipated occupational exposure to blood or other potentially infectious material [9]. In 1993, the European Parliament adopted resolution A3/0027/93, calling for vaccination of HCWs and other at-risk occupations against hepatitis B and recognizing hepatitis B as the most important infectious occupational disease in Europe [10]. In Greece, vaccination against hepatitis B has been started as National Vaccination Programme since 1/1/1998, under law no 4543/10-9-97 [11]. Hepatitis B vaccination (HBv) compliance among various groups of HCWs shown in Table 1. We conducted the first to our knowledge crosssectional survey of a nationally representative sample of Greek military hospitals (Gmh), to estimate hepatitis B vaccination coverage levels among nursing personnel and to describe factors associated with vaccination coverage rates. Material and Methods The study took place at seven Military Hospitals located all over Greece. The study was reviewed and approved by each Hospital Review Board prior to data collection. Subjects consisted of all registered nurses and nurses aides who were working at the hospital during the survey as permanent stuff and had direct contact with patients. Non-permanent nursing personnel, nurses that had not direct contact with patients and students were excluded from the study. Hepatitis B vaccine was available free of charge to all hospital employees by Hospital Infection Control Committee (HICC). Anonymous self-administrated questionnaires were distributed and turned back two weeks later. The questionnaire was developed by the researchers after a thorough review of literature so as to elicit information about study purposes. In order to establish content validity we tried to achieve a representative Balkan Military Medical Review Vol. 12, No. 4, October 2009 sample. The hospitals were chosen to reflect the known distribution of nursing personnel by facility type and location. Three infection control specialists and a statistician ranked the questionnaire. The original version was circulated among a number of nurses. Comments and suggestions were incorporated into the questionnaire and the revised version was circulated to a separate group of nurses. Internal consistency reliability was established with Cronbach, which found to be 80%. The survey instrument included a number of questions covering the following areas; (i) socio-demorgaphics and employment characteristics (sex, age, years in service, specialty, rank, work setting, education, post graduate studies), (ii) accepted number of doses of hepatitis B vaccine and (iii) knowledge about basic issues regarding hepatitis B vaccine. Hepatitis B vaccination coverage rate was calculated by dividing the weighted number of HCWs who had received 3 or more doses of hepatitis B vaccine, by the weighted number of HCWs answered the relative question. The factors that correlated with hepatitis B vaccine acceptance were divided in two groups. One group included HCWs and hospital's socio-demographic characteristics and the other group included attitudes, beliefs and statements about hepatitis B vaccine issues. Statistical analysis Data were analyzed by SPSS-13 for Windows software. Descriptive statistics, 95% confidence intervals and odds ratio (crude and adjusted) were calculated. Differences among hospitals in the proportion of nurses were evaluated with x2 statistic test with Yates correction. A logistic regression model was used to identify variables with the strongest impact on hepatitis B vaccine acceptance. A multivariate logistic regression was developed using backward elimination and forward selection of variables to identify primary predictors hepatitis B vaccination intention. An initial model was created using univariate analysis with x 2 statistics, selecting all variables associated with hepatitis B vaccination with a p value less than 0,05. Predictors were included in the final model if they had a p value less than 0,05. We tested for all 2-way interactions of variables in the final model. Associations were assessed by evaluating the adjusted odds ratio.

Tsoulas D. et al.: Hepatit B vaccination in health care workers 135

136 Balkan Military Medical Review Vol. 12, No. 4, October 2009

Tsoulas D. et al.: Hepatit B vaccination in health care workers 137

138 Balkan Military Medical Review Vol. 12, No. 4, October 2009

Tsoulas D. et al.: Hepatit B vaccination in health care workers 139 Results A total of 245 out of 410 questionnaires were returned properly answered from the nurses who participated in the study (60% response rate). The respondents spent their time working in an impatient unit and mostly in close contact with patients during an average workweek. There were 138 registered nurses and 107 nurse aids of whom 29 were men and 216 were women. More than half of the respondents (54%) were between 34 and 65 years old, 51% of them had more than 12 years in service and the majority worked at hospitals of Athens (66%). Demographic and employment characteristics of the respondent staff, along with hospital characteristics are listed in Table 2. Overall, 75,5% of HCWs reported vaccination with 3 doses of hepatitis B vaccine: 58,4% (108/185) were registered nurses and 41,6% (77/185) were nurse aids Registered nurses had 2-fold higher odd of vaccination compared with nurse aids (Odds Ratio:2,19; 95% Confidence Interval 1,21-3,97, p<0,001). Nearly 37% of noncompliant HCWs (22/60) did not receive even a single dose of the vaccine, whereas almost 38% had no knowledge at all about prior hepatitis B vaccination history. Regarding hospital characteristics, hospitals of Athens with more than 250 beds capacity appear higher hepatitis B vaccination rates, than hospitals located in the rest of Greece with less than 250 beds. As far as working departments, the highest vaccination percentage was observed in the renal dialysis units, with 88% of nurses having completed 3 doses hepatitis B vaccination. However in both these findings, statistical significance was not established. Using bivariate analysis, other socio-demographic factors associated with higher odds of hepatitis B vaccination were age under 34 years old and less than 12 years in service. Moreover several attitudes and beliefs were described with statistical significant higher odds for accepting hepatitis B vaccine. Respondents who had vaccinated with more than half of the vaccines that are strongly recommended for HCWs by National [8,11] and CDC [12-14] guidelines, had almost 6-fold higher odds of vaccination. Nurses that were informed about vaccines' safety and efficacy had respectively 3 and 5,5- fold greater odds of vaccination. Finally HCWs who had a knowledge level about hepatitis B vaccination issues above median and perceived hepatitis B infection as a serious occupational threat had also almost 3 times higher odds of vaccine acceptance (Table 3). In the multivariate model the adjusted odds of hepatitis B vaccination among nursing personnel was significantly higher for registered nurses and those who were under 34 years old. Moreover statistical significant higher odds for accepting hepatitis B vaccine was established for respondents who had vaccinated with more than half of the vaccines that are strongly recommended for HCWs by National [8,11] and CDC [12-14] guidelines, who were informed about vaccines' safety and efficacy, who had a knowledge level about hepatitis B vaccination issues above median and who perceived hepatitis B infection as a serious occupational threat. (Table 4). The majority of vaccinated respondents (178/185) accepted hepatitis B vaccine for their personal protection, while the rest (7/185) because it was recommended from HICC. Younger registered nurses (<33 years old) with less than 12 years in service strongly believed that vaccination could protect them from hepatitis B infection. However differences among groups failed to achieve statistical significance. Of the 60 unvaccinated HCWs in the survey almost one fifth refused vaccination because they didn't find available time, while 6,6% was concerned about vaccines' side effects. Finally nearly one third didn't state any specific reason for declining vaccination. Discussion Although several studies have examined staff rates of hepatitis B vaccination, comparison is difficult because reported rates differ based on the type of healthcare facility, geographic location, interventions implemented, type of staff included and survey methods that had been followed. In the present study the overall compliance to hepatitis B vaccination of 75,5% observed among HCWs of Gmh appears higher of 48,6% and 57,1% reported from other Greek researchers [15-17]. However lower compliance rates of

140 8,8% [18], 13% [19], 40% [20, 21], 56% [22] have been reported in the literature. Our study's hepatitis B vaccination compliance rate seems reasonable and comparable with 78% reported from nurses of Australia [23] and 78% [24] and 72% [25] reported from USA emergency medical technicians/paramedics and nurses respectively. A similar 79,5% hepatitis B vaccination compliance rate is also estimated among nurses in Saudi Arabia [26]. However our finding still falls short from described rates, 83% from UK [27], 81% from USA [28], 88% from Italy [29] and 94% from Brazil [30] (Table 1). Study design, survey methods, type of staff included and vaccination intervention implemented could explain reported different rates. Regarding socio-demographic factors that influence vaccine acceptance, we found that registered nurses, who were under 34 years old and with less than 12 years employment have statistically significant higher odds of vaccination. Hepatitis B vaccination coverage is reported higher among nurses in comparison with nurse aids, phlebotomists and medical technicians in several studies [25-28]. Additionally younger age and less years of employment were also described from other researchers as independent predictors of vaccine uptake among HCWs [28-31]. However race is also described as strong determinant of hepatitis B vaccination [28]. Whereas several socio-demographics and employment characteristics were not statistically significant, we found that certain attitudes and beliefs were significantly correlated with greater odds of hepatitis B vaccination: (i) belief that vaccine is effective and safe, (ii) vaccination with more than half of the vaccines that are strongly recommended by HCDCP [8,11] and CDC [12-14) for HCWs, (iii) perceived susceptibility to hepatitis B infection due to their occupation and (iv) knowledge level above median on hepatitis B vaccination issues. In our study none of hospital characteristics were associated with vaccination coverage because all military hospitals had a joint vaccination policy in place that required hepatitis B vaccination for all HCWs. However there is strong evidence supporting that HCWs were less likely to be vaccinated if they were employed in hospitals that had policies either requiring or offering hepatitis B Balkan Military Medical Review Vol. 12, No. 4, October 2009 vaccine to those without occupational exposure to blood or other potential infectious body fluids [28]. According to the researchers it is possible that such policies might divert attention and resources from vaccination of HCWs who are at occupational risk for hepatitis B infection. On the contrary in a study about hepatitis B coverage among HCWs in Italy [29], found that location of the hospital has a performance characteristic of hepatitis B vaccination, with vaccination coverage increasing significantly from South (78%) to the North (93%). Other researchers found higher hepatitis B vaccine uptake in the sub district hospitals and smaller health centers in comparison with district hospitals [19]. Moreover it is reported that hepatitis B vaccination coverage was higher for United States hospitals with 100 beds or less, compared with hospitals with 101-400 beds and hospitals with more than 400 beds [25]. Also in the same study a number of vaccination policies were associated with increased vaccination coverage such us: use of reminder notices, notifying supervisor if an employee refused vaccination, use of incentive encouragement, imposing sanctions for refusing vaccination. We have found that the most common reason for avoiding vaccination was being busy and not having time for it. In a study on acceptance of hepatitis B vaccine among paramedics and medical technicians, it was reported that reasons for avoiding immunization were fear of contracting hepatitis B infection from the vaccine, vaccination scheduling difficulties and lack of time to get vaccinated [24]. Having a belief of risk free exposure and not working in nursery service were reported as other reasons for avoiding vaccination [32]. Our study is limited by reliance on self-reported hepatitis B vaccination status and recall bias. However literature review has shown excellent agreement between self reported vaccine status and medical records. Also we estimate that geographic distribution and the representative sample counterbalances for the small number of responders. Implications for practice We conclude that hepatitis B vaccination rate among nurses in Gmh is satisfactory but progress can be established. Further research is warranted

Tsoulas D. et al.: Hepatit B vaccination in health care workers 141 to examine hepatitis B vaccination and other hepatitis B infection control practices within Gmh and efforts should be tailored to increase vaccination coverage. It is strongly recommended that, healthcare facilities should take steps to provide all HCWs easy access to hepatitis B vaccine at their work site. In conclusion, so as to increase hepatitis B coverage rates innovative strategies may be needed. Study results indicate that hepatitis B education should be associated with effective vaccine delivery system and organizational interventions to overcome reported barriers and alleviate common misconceptions about the vaccine. Educational campaigns must be conducted with the aim of enhancing their knowledge regarding the safety, efficacy and benefits of vaccination. Organizational and administrative interventions that have been found effective to increase hepatitis B vaccination rate among HCWs are: on site vaccinations, mobile carts, post card reminders and motivations for accepting the vaccine. Our data also suggest that effort should focus to older and experienced nurses. Finally acknowledgement of National and CDC vaccination policy is another successful strategy to increase staff's compliance. Acknowledgements We wish to express our acknowledgements to all nurses who respondent to our survey and contributed to the collection of the data and also to Infection Control Specialists and the statistician who contributed to the development of the questionnaire. Conflict of interest statement: Authors report no conflict of interest relevant to this article References 1. Hileman MR. Overview of the pathogenesis, prophylaxis and therapeusis of viral hepatitis B, with focus on reduction to practical applications. Vaccine 19:1837-48, 2001. 2. Cardo DM, Bell DM. Blood borne pathogen transmission in HCWs. Infect Dis Clin North Am 11:331-43, 1997. 3. Beltrami EM, Williams IT, Shapiro CN, et al. Risk and management of blood-borne infections in hcws 13:385-407, 2000. 4. Center for Diseases Control. Protection against viral hepatitis: recommendations of the Advisory Committee on Immunization Practices MMWR Morb Mort Wkly Rep 39(RR-2):1-27, 1990. 5. World Health Organization. Prevention of hospital acquired infection: a practical guide. 2nd edition. WHO, Department of Communicable Diseases; p.61, 2001. 6. Bonanni P, Bonaccorsi G. Vaccination against hepatitis B in health care workers. Vaccine 19:2389-94, 1999. 7. World Health Organization. Where is hepatitis B more common? Available at. http://www.who.int/mediacentre/factsheets/fs204/e n/index.html (accessed in August 2009). 8. Hellenic Center for Diseases Control and Prevention (HCDCP). Recommendations for vaccination against hepatitis B, 2004. Available at: http://www.keel.org.gr/keelpno/2007/id610/sistaseis_emvolio_b.pdf (Greek) (accessed in August 2009). 9. US. Department of Labor Occupational Safety and Health Administration. Bloodborne Pathogens 29CFR 1910.1030, 1991. 10.Resolution A3/0027/93, Off J Eur Commun C72:41-43, 1993. 11.Hellenic Center for Diseases Control and Prevention. Guidelines for the management of health care workers' occupational exposure to HBV, HCV and HIV and recommendations for postexposure prophylaxis. 2004. Available at: http://www.keel.org.gr/ipatitides/docs_pdf/expotion_pro.pdf (Greek) (accessed in August 2009). 12.Boylard EA, Tablan OC, Williams WW, et al. Guidelines for infection control in hospital personnel. The Hospital Infection Control Practices Advisory Committee (HICPAC). Am J Infect Control 26:289-354, 1998. 13.Center for Diseases Control and Prevention. Immunization of HCWs: recommendations of the Advisory Committee on Immunization Practices and the Hospital Infection Control Practices Advisory Committee. MMWR Morb Mort Wkly Rep, 46 (RR-18):1-42, 1997. 14.Center for Diseases Control and Prevention. Updated US public health service guidelines for the management of occupational exposure to HBV, HCV and HIV and recommendations for postexposure prophylaxis, MMWR Morb Mort Wkly Rep 50:1-42. 2001 15.Antypa A, Pouyouka M, Karabasi V, et al Seroepidemiologic survey of hepatitis B markers in HCWs of a major Greek Hospital. J Chemother 17(suppl.3):129, 2005. 16.Skliros EA, Papoulia E, Vlahos DG, et al. HBV infection markers in hospital personnel. Relations

142 to personal vaccinations. Iatriki Epitheorisi Enoplon Dynameon, 31:97-100, 1997. 17.Rachiotis G, Goritsas C, Alikakou V, et al. Vaccination against Hepatitis B virus in workers of general hospital in Athens. Med Lav, 96(1):80-6, 2005. 18.Talaat M, Kandeel A, El-Shoubary W, et al. Occupational exposure to needlestick and hepatitis B vaccination coverage among health care workers in Egypt. Am J Infect Control, 31:469-74, 2003. 19.Suckling RM, Taegtmeyer M, Nguku PM, et al. Susceptibility of healthcare workers in Kenya to hepatitis B: new strategies for facilitating vaccination uptake. Journal of Hosp Infect, 64:271-7, 2006. 20.Dannetum E, Tegnell A, Torner A, Giesecke J. Coverage of hepatitis B vaccination in Swedish healthcare workers. J Hosp Infect, 63(2):201-4, 2006. 21.Fatusi AO, Fatousi OA, Esimai AO, Onayade A, Ojo O, et al. Acceptance of hepatitis B vaccine by workers in Nigerian teaching hospital. East Afr Med J, 77 (11):608-12, 2006. 22.Hatipoglou CA, Yetkin MA, Ergin F, et al. Vaccination of healthcare workers against HBV in a teaching hospital. The Hospital Infection Society. 5:200-2, 2006. 23.Brotherton JML, Bartlett MJ, Muscatello DJ, et al. Do we practice what we preach? Health care worker screening and vaccination. Am J Infect Control, 31:144-50, 2003. 24.Lee DJ, Carillo L, Fleming L. Epidemiology of Hepatitis B vaccine acceptance among urban paramedics and emergency medical technicians. Am J Infect Control, 25:421-3, 1997. Balkan Military Medical Review Vol. 12, No. 4, October 2009 25.Mahoney FJ, Stewart K, Hanxian H, Coleman P, Alter MJ. Progress towards the elimination of Hepatitis B virus transmission among healthcare workers in the United States. Arch Intern Med, 157:2601-5, 1997. 26.Panhotra BR, Saxena AK, Al-Hamrani HA, Al- Mulim A. Compliance to hepatitis B vaccination and subsequent development of seroprotection among HCWs of a tertiary care center of Saudi Arabia. Am J Infect Control, 33:144-50, 2005. 27.Gyawali P, Rice PS, Tilzey AJ. Exposure to blood borne viruses and the hepatitis B vaccination status among healthcare workers in inner London. Occup Environ Med, 55:570-2, 1998.Simard EP, Miller JT, Prethibha A, et al. Hepatitis B vaccination coverage levels among healthcare workers in the United States, 2002-2003. Infect Control Hosp Epidemiol, 28(7):783-90, 2007. 29.Stroffolini T, Coppola R, Carvelli C, et al. Increasing hepatitis B vaccination coverage among healthcare workers in Italy 10 years apart. Dig and Liv Dis 40: 275-7, 2007. 30.Manso VFC, Castro KF, Matos SM, et al. Compliance with hepatitis B virus vaccination and risk of occupational exposure to blood and other body fluids in intensive care department personnel in Brazil. Am J Infect Control, 31:431-4, 2003. 31.Shapiro GN, Tokars JI, Chamberland ME. Use of the hepatitis B Vaccine and Infection with Hepatitis B and C among Orthopaedics Surgeons. The Journal of Bone and Joint Surgery, 78A (12):1791-80, 1996. 32.McEwen M, Farren E. Actions and Beliefs Related to Hepatitis B and Influenza Immunization among Registered Nurses in Texas. Public Health Nursing 22(3):230-239, 2005.