Compliance of Health Workers to H1N1 Vaccination

Volume 1 Issue 1, December 211, Pages 1-8. Compliance of Health Workers to H1N1 Vaccination Ankur Sarin, Prof. Jugal Kishore, Dr. Charu*, Dr. Tanu Anand, Dr.Urvi Sharma Department of Community Medicine, Maulana Azad Medical College, New Delhi, India Abstract Vaccination for pandemic influenza is considered to be one of the most important primary preventive measures to reduce the disease burden of H1N1. Healthcare workers have been identified as a first priority to be vaccinated against influenza A (H1N1) but there is paucity of data about knowledge, current status, willingness and factors associated with acceptance in Indian setting. A cross-sectional study was carried out on 76 healthcare workers in a tertiary care teaching hospital of Delhi. All doctors were aware of H1N1 whereas only 46 of other healthcare workers had heard about it. Television was the most popular source of information among all types of workers. All doctors and 86 of other healthcare workers had knowledge of the transmission of H1N1 infection. Only 32 doctors, 25 nurses and only 1 technicians had been trained on H1N1. Practice of getting vaccination was maximum among nurses (3) followed by doctors (13) and least among technicians and ward boys. Responding to why they had not received the vaccination, 42 of doctors considered the vaccine ineffective, 6 of the technicians thought that they did not need the vaccine. It is concluded that acceptance rate of H1N1 vaccination is low amongst healthcare workers. There is an immediate need for spreading correct awareness about the vaccine and its role in preventing H1N1 infection. Keywords: H1N1 vaccination, swine flu, healthcare workers, acceptance of vaccine *Author for Correspondence Email: kohlicdoc17@gmail.com, Phone: +91-91356699 1. INTRODUCTION The H1N1 pandemic originated from swine (pig) caused by influenza A virus subtype H1N1 virus strain. The influenza virus has the characteristics of antigenic variation due to antigenic shift and drift. The swine acts as a re-assortment vessel in which various viruses could be mixed together and a new type of virus emerges, such as H1N1 which was the outcome of mixing of swine flu, American flu, avian flu and human flu. The human race does not have immunity against this new reassorted and novel virus; that is why this virus has the potential to spread worldwide. The epidemic started in Mexico in March, 29, and spread throughout the world within two months time. The first case of H1N1 in India was found on the Hyderabad airport on 13 May, 29, in a person travelling from the United States to India [1]. Subsequently, more confirmed cases were reported and the rate of transmission of the flu increased in the beginning of August, 29, when the first death due to swine flu was reported in Pune, India [2]. The 29 pandemic of influenza A (H1N1) infection alerted many governments to make preparedness plans to control the spread of influenza A (H1N1) infection. With evidence on the effectiveness of vaccination in the control and prevention of seasonal influenza [3, 4], vaccination for pandemic influenza is one of the most important primary preventive measures to 1

Volume 1 Issue 1, December 211, Pages 1-8. reduce the disease burden associated with influenza A (H1N1) infection [5]. The vaccine either contains live viruses (attenuated) or killed (inactivated) viruses, with and without adjuvants. The vaccine is usually based on the viral strain called A/California/7/29 (H1N1). Alum or thiomersal is used as adjuvant to increase the vaccine s potency. The adjuvants used in H1N1 vaccines are alum or squalenebased. The former has been used in many vaccines for about 6 years and the latter, which is an extract of fish oil, in seasonal flu vaccines since 1997. This vaccine does not provide protection against other influenza viruses. It is effective about 1 to 14 days after vaccination. People infected by H1N1 just before (one to three days) or after vaccination can still get the disease. The inactivated vaccine is given by injection into the upper arm and into the thigh in infants and younger children. The live attenuated vaccine is administered by a nasal spray. Several high risk groups have been identified as the priority population to receive the influenza A (H1N1) vaccination and among these, healthcare workers have been identified by the World Health Organization as a first priority to be vaccinated [6, 7]. Previous studies have found low acceptability of influenza vaccination among healthcare workers [8, 9]. Therefore, willingness of the healthcare workers as well as their fears to accept the H1N1 vaccination needs to be assessed so that an awareness program can be designed accordingly. Keeping all these aspects in view, this study was planned to find the awareness about H1N1 vaccination, current status of vaccination, willingness to accept vaccination and factors associated with the practices for vaccination against H1N1 among healthcare workers. 2. METHODS 2.1. Study Design, Participants and Sampling Technique We conducted a hospital-based crosssectional study in a tertiary care teaching hospital of Delhi. Seventy-six healthcare workers that included nursing staff, doctors, technicians and ward boys were selected from microbiology, medicine departments, casualty and swine flu ward in proportion to their size. Healthcare workers of these particular fields were selected as they come in frequent contact with patients who could be exposed to influenza virus. The sample size calculation was based on a previous study done in Hong Kong where compliance rate among healthcare workers for H1N1 vaccine was 27, worst acceptable rate of 17 with 95 confidence level which came out to be 74. 2.1.1. Study Tool A pre-tested predesigned questionnaire consisting of items on demographic profile, knowledge about H1N1 infection, attitude and acceptance of vaccination against H1N1 and reasons for compliance was used to collect the information from each selected healthcare worker. 2.1.2. Statistical Analysis The data collected was entered in MS- Excel and analysed using EPI-INFO 25 software package of World Health Organisation (WHO). Results were presented in simple proportions and differences among groups were assessed for their statistical significance using chisquare test and accepted significant if p value was less than.5. 2.1.3. Ethical Issues The participants were explained the purpose of the study. The information collected was kept confidential and their informed consent was taken before taking information. 2

Volume 1 Issue 1, December 211, Pages 1-8. 3. RESULTS Out of 76 healthcare workers who participated in the study, 55.3 were male and 44.7 female. 4.8 were doctors, 26.3 nurses, 13.2 technicians and 19.7 were ward boys. Healthcareworkers were more from medicine (6.52), and microbiology departments (26.31) and 6.57 each from casualty and swine flu ward (Table I). 3

Volume 1 Issue 1, December 211, Pages 1-8. The study showed that all doctors (n=31; 1) had heard about H1N1 whereas only 46 of other healthcare workers had heard about H1N1. This difference was statistically significant (χ 2 = 24.16, p <.1). Overall knowledge of doctors about swine flu was significantly more as compared to other health care workers (χ 2 = 6.16, p <.13) as shown in the Table II. Table II Knowledge of health workers about H1N1/Swine Flu and its source of information. Question Doctors (n = 31) Technician s (n = 1) Nurses (n = 2) Ward boys (n = 15) Total (n = 76) Heard about H1N1 31 (1) 5 (5) 14 (7) 2 (3.3) 52 (68) Sources of Information 1) Training 2) Posters 3) Newspapers 4) Colleagues 5) T.V. 6) Others 31 (1) 15 (48.3) 5 (16) 25 (8.6) 12 (38.7) 25 (8.6) 2 (6.4) 1 (1) 2 (2) 2 (2) 9 (9) 1 (1) 9 (9) 17 (85) 7 (35) 2 (1) 16 (8) 5 (25) 16 (8) 1 (66.6) 3 (2) 4 (26) 9 (6) 1 (6.6) 11 (73.3) 68 (89) 27 (35) 13 (17) 59 (77) 19 (25) 61 (8) 2 (2.6) How is Swine Flu Transmitted? Answer Droplet Infection Your Work Increases the Risk of Swine Flu? Answer Yes 31 (1) 1 (1) 17 (85) 11 (73) 69 (9.7) 25 (8.6) 9 (9) 16 (8) 9 (6) 59 (77) Can It be Prevented by Vaccination? Answer Yes 15 (48.3) 1 (1) 17 (68) 1 (66) 52 (68) Is There Facility of H1N1 Vaccination in Your Hospital? Answer Yes Have You Received Training on H1N1? 14 (45) 9 (45) 23 (3) 1 (32) 1 (1) 5 (25) 16 (21) Among the various sources of information, television was the most popular source among all types of workers. Doctors were getting information about swine flu from colleagues significantly more than other workers (χ 2 = 5.25, p =.2). There is no significant difference in information derived by both groups from training, posters, newspapers and T.V. All doctors had knowledge about the transmission of 4

Volume 1 Issue 1, December 211, Pages 1-8. swine flu which is statistically significant (χ 2 = 5.31; p =.2) as compared to the knowledge among other healthcare workers (86). 81 of the doctors felt that the nature of their work predisposes them to swine flu infection while 77 of other workers felt so, but this difference was not statistically significant. Significantly, less percentage of doctors (48) as compared to other healthcare workers (78) thought that swine flu can be prevented by vaccination (χ 2 = 9.73, p =.1) but significantly more doctors were aware of facility of H1N1 vaccination in their hospital than the other healthcare workers (χ 2 = 5.51 p =.1). 32 doctors said they received training on H1N1 while 25 nurses and only1 technicians received training on H1N1.None of the ward boys was trained on H1N1. Thus, significantly more doctors than other healthcare workers had received training on H1N1 (χ 2 = 3.96; p =.4). The practice of getting vaccination was maximum among nurses followed by doctors and least among technicians and ward boys. The difference in compliance to vaccine between doctors and other healthcare workers is not statistically significant (χ 2 =.1 p =.95). Only 13 of doctors had received H1N1 vaccination as shown in Table III. Table III Practice of healthcare workers regarding H1N1 vaccination according to their designation. Question Have You Received H1N1 Vaccination? Doctors (n = 31) 4 (13) Technicians (n = 1) Nurses (n = 2) 6 (3) Ward boys (n = 15) Total (n = 76) 1(13) If not, why 1) No Need 2) Vaccine Not Effective 3) Side Effects 4) Pregnancy/Ill Heath H1N1 Infection 5) Not Provided Free 6) Don t Know from Where I Can Get It 7) Any Other 3 (9.6) 13 (42) 2 (6.4) 1 (3.2) 4 (13) 2(6.4) 1 (32) 6 (6) 1 (1) 3 (3) 1 (5) 3 (15) 3 (15) 3 (15) 1 (5) 1 (6.6) 3 (2) 8 (53) 11 (14) 14 (18) 2 (2.6) 4 (5) 1 (13) 16 (21) 2 (2.6) Do You Wash Your Hands with Soap and Water/Antiseptic before and after Touching the Patient? 19 (61) 1 (1) 16 (8) 11 (73) 56 (73.6) A considerable percentage of doctors (42) thought that the vaccine is ineffective. 6 of the technicians thought that they do not need the vaccine, while 15 nurses and as many as 53 ward 5

Volume 1 Issue 1, December 211, Pages 1-8. boys were not aware from where they can get themselves vaccinated. Only 4 men and 6 women had taken the vaccination. The practice of hand washing was statistically significant, being more in healthcare workers than in doctors (χ 2 = 4.5; p =.4) where only 61 doctors but 84 of other healthcare workers used to wash their hands with soap after touching the patient. When asked about the knowledge of methods for preventing H1N1/swine flu, mask was the most common method which was followed by vaccine. The results are shown in Figure 1. Figure 1 Knowledge of Methods of Prevention against Swine Flu. When inquired about the knowledge about other diseases, all doctors and technicians were aware about human influenza, tetanus, hepatitis, measles and SARS whereas only 15 nurses and 13 ward boys had knowledge about SARS (data is not presented). All healthcare workers were found to be vaccinated for tetanus. Apart from 7 ward boys, all health workers were vaccinated for hepatitis. All doctors and technicians received measles vaccine while 36 ward boys and 1 nurses had not taken the measles vaccine (Table IV). Table IV Vaccination status of healthcare workers. Question Have You Received the Vaccination for Following 1) Human Influenza 2) Hepatitis 3) Measles 4) Tetanus Doctors (n = 31) 4 (13) 31 (1) 31 (1) 31 (1) Technicians (n = 1) 1 (1) 1 (1) 1 (1) Nurses (n = 2) 6 (1) 2 (1) 18 (9) 2 (1) Ward boys (n = 15) 14 (93) 1 (66) 15 (1) Total (n = 76 1 (13) 75 (98.6) 69 (9.7) 76 (1) 6

Volume 1 Issue 1, December 211, Pages 1-8. 4. DISCUSSION It was found that all doctors had heard about H1N1 whereas only 46 of other healthcare workers had heard about H1N1. Television, training, newspapers and peers or colleagues were the most common sources of information. Thus, these sources can play an important role in giving information to healthcare workers and can help to change their attitude towards acceptance of vaccine and knowledge about beneficial preventive practices for H1N1. The study showed that healthcare workers were well aware that swine flu spread by droplet infection. Doctors knowledge about transmission of swine flu was significantly more than the knowledge of other healthcare workers. As much as 81 doctors and 77 of other healthcare workers believed that they were more susceptible to swine flu infection than common man. This is due to the nature of their work as healthcare workers have frequent contact with patients. It was found that 42 doctors believed the vaccine is not going to prevent swine flu. Some studies have documented that because H1N1 vaccine is relatively a new vaccine, which has not been tested adequately, and concerns about the side effects were some of the reasons that healthcare workers cited for not willing to accept vaccination against H1N1 [1] A significant percentage of doctors received H1N1 training as compared to other health workers but it is clear that there is a need to train more doctors, nurses, technicians and ward boys to deal with future outbreaks. Only 13 doctors and 3 nurses had been vaccinated. Thus the compliance was found to be very low. Among doctors, 42 thought that vaccine is not effective. Technicians thought that they need not get themselves vaccinated because they thought they have lesser contact with the patients. However, technicians are the ones dealing with patient s body fluids like sputum. Thus, it is of utmost importance that they should be vaccinated. 3 technicians, 15 nurses and as many as 53 ward boys had no knowledge from where to get the vaccine even though in the hospital, where these healthcare workers were working, vaccination was given free of cost to its workers. This kind of unawareness can affect those who would have taken the vaccination had they known that it is available in their hospital and that too free of cost. Also, the vaccine was not taken by 15 nurses because of ill health or pregnancy. However, The Centre for Disease Control and Prevention has put pregnant women on priority for vaccine because they are at a higher risk of complications and can potentially provide protection to infants who cannot be vaccinated [11]. Even though doctors are more knowledgeable, the practice of hand washing is statistically more significant in other healthcare workers than doctors. This could be due to high patient to doctor ratio especially in a hospital like the one in which this study has been carried out. Knowledge about preventing swine flu was assessed and it was found that mask was the most common method known to healthcare workers to prevent swine flu, which was followed by vaccine. Few thought that drugs and hand wash are other simple methods to prevent swine flu. Thus, there is a clear need for educating all healthcare professionals including the doctors about methods of prevention of swine flu and importance of hand washing. Doctors and technicians were found to be well aware of all the diseases like human influenza, SARS, hepatitis, measles and tetanus. This is due to their higher education levels. Nurses and ward boys were least aware about the diseases. A high percentage of healthcare workers were vaccinated with measles, tetanus and hepatitis but very few had taken the influenza vaccine. This is due to the fact that these diseases are being given priority 7

Volume 1 Issue 1, December 211, Pages 1-8. over influenza in the country. Moreover, the vaccine for measles and hepatitis is in the National Immunization Schedule in India [12]. The acceptance rate of H1N1 vaccination is low amongst healthcare workers. The overall acceptance rate was 13, which is even lower than acceptance rate in previous studies done in other parts of the world [13]. Even though doctors are better educated than nurses, it was found that a higher percentage of nurses had taken the vaccination as compared to the doctors. It is important to note that significant percentage of doctors thought that the vaccine is not effective. 5. CONCLUSIONS Thus, the study shows that there is an immediate need to spread awareness about the vaccine and its role in preventing H1N1 infection. Other methods of preventing H1N1 infection like hand washing, cough etiquettes and anti-viral drugs must be propagated. Many health workers did not know from where they could get themselves vaccinated. Thus institutions providing the vaccine need to advertise so that people can know from where they can get themselves vaccinated. Since healthcare workers are at a high risk of contracting influenza infection, and play a significant role in caring for community, special attention should be paid to this group as successful vaccination strategy has been shown to be beneficial in prevention of disease transmission. ACKNOWLEDGEMENTS This project was done as a part of short term studentship (STS-26) received by the first author from the Indian Council of Medical Research. Their support is greatly acknowledged by the author. REFERENCES 1. IBN. First Case of Swine Flu Confirmed in India. 17 May 29. Available from: http//ibnlive.in.com/news/firstcase-of-swine-flu-confirmed-inindia/92733-3.html 2. LIVEMINT. The Wall Street Journal. First Swine Flu Death Confirmed in India. August 4, 29. Available from: http://www.livemint.com/29/8/ 494251/First-swine-flu-deathconfirme.html. 3. Nichol K.L. et al. Journal of Infectious Diseases. 26. 194(S2). 111 118p. 4. 4. Nichol K. L. Vaccine. 28. 26 (S4). 17 22p. 5. Jennings L.C., Monto A.S., Chan P.K. et al. Lancet Infectious Diseases. 28. 8(1). 65 658p. 6. Zarocostas J. British Medical Journal. 29. 339. 2877p. 7. WHO. World Health Organization. 29. 8. Martinello R.A., Jones L., Topal J.E. Infection Control and Hospital Epidemiology. 23. 24(11). 845 847p. 9. Qureshi A.M., Nughes N.J., Murphy E. et al. Occupational Medicine. 24. 54(3).197 21p. 1. Seale H., Kaur R., Wang Q. et al. Vaccine. 211. 29(8).165 161p. 11. CDC. Centres for Disease Control and Prevention. 211. Available from: http://www.cdc.gov/h1n1flu/vaccin ation/acip.html 12. WHO. WHO India. Available from: http://whoindia.org /en/ Section6/Section284/Section286_5 8.html 13. Abramson Z. and Levi O. Vaccine. 211. 26(2). 2482 2489p. 8

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