Abstract
Background:
Vaccination is one of the most effective interventions used to reduce infections. Nonetheless, concerns and misconceptions about vaccines have resulted in an increased rate of refusal of vaccination among healthcare workers (HCWs) and within the general population.
Aim/ Objective:
To understand the factors that underlie vaccination-refusal.
Methods:
A questionnaire was given to the HCWs in the inpatient area of an acute London hospital during May 2019. The sample was one of convenience, i.e. the wards where the principle investigator covered. All staff were approached: 306 in total completed the questionnaire.
Findings/results:
In total, 212 (69.28%) healthcare professionals had the flu vaccine during the 2018–2019 campaign, 94 (30.62%) did not have the flu vaccine and 37 (39.36%) of the HCWs that did not receive the flu vaccine reported they had previously a bad reaction following administration of the vaccine.
Discussion:
This report will provide the Trust and other healthcare settings with information integrating the disconnection between misconceptions and vaccination knowledge, which may inform practical interventions to address the challenges of vaccination in future campaigns. Increasing HCWs’ knowledge of flu vaccine side effects could address this and may increase rates of vaccination compliance.
Keywords: Influenza, vaccination, infection control, healthcare workers, flu, anti-vaccine
Background
Vaccines are one of the most effective instruments to prevent infections. Since vaccines were routinely introduced in the general population, there has been a decline in the number of infections and related mortality (World Health Organization [WHO], 2008). An evidence-based literature review investigated the reasons of H1N1 vaccine uptake (Bish et al., 2011). They conclude that vaccination against the flu virus is sub-optimal around the world. In 2010, 40% of healthcare workers (HCWs) in England had the flu vaccine. The review indicates that the explanation for low uptake of the flu vaccine is due to the perception of low susceptibility to developing H1N1 influenza, low levels of concern about the disease, and fears about the side effects and safety of the vaccine.
Nonetheless, concerns about vaccines and spread of misinformation by anti-vaccine groups have resulted in increased concerns and a declining rate of vaccination uptake, not only within the general population but also in HCWs who are refusing the flu vaccine offered every year. According to the WHO, the vaccination rate among HCWs has declined in Europe (Petek and Kamnik-Jug, 2018). Compliance of HCWs with the flu vaccine in NHS England Trusts during 2018–2019 was 70.3% (Public Health England [PHE], 2019). Refusal of the flu vaccine increases the risk of contracting flu and transmitting it to the most vulnerable patients in the hospital environment.
This self-report questionnaire study explores the reasons for vaccine refusal of the HCW population in an acute London teaching hospital. The results were analysed according to healthcare group and related to their level of education/understanding. These results will help the infection prevention and control (IPC) team to target specific groups and formulate specific strategies to improve compliance in future vaccination campaigns. These results could be applied to other healthcare settings.
Methods
A questionnaire with three parts was designed for the study. The first part is demographic, where the HCW anonymously marks their role. In the second part, the HCW marks whether they had the flu vaccine in the last year (2018–2019). If the answer is no, the HCW marks the reason why they choose not to receive the vaccine. The questionnaire had 11 options for opting out: I do not like needles; I got sick after the vaccine; the vaccine does not work; I never get flu; I am vegan; it is contraindicated for me; it was not offered to me; I could not find the vaccine; I do not want to have the vaccine; or other. This questionnaire was not piloted as it followed a similar format to our opt-out forms in previous campaigns. Results are displayed in Tables 1 and 2.
Table 1.
Flu vaccine compliance by HCW groups.
| Nurse (182) | Student Nurse (19) | Doctor (51) | HCA (43) | Clinical clerk (11) | Total | % | |
|---|---|---|---|---|---|---|---|
| Yes | 127 | 13 | 38 | 26 | 8 | 212 | 69.28 |
| No | 55 | 6 | 13 | 17 | 3 | 94 | 30.72 |
| Total | 182 | 19 | 51 | 43 | 11 | 306 | 100.00 |
| Compliance (%) | 69.78 | 68.42 | 74.51 | 60.47 | 72.73 | 69.28 |
Table 2.
Reason for refusal.
| Nurse | Student nurse | Doctor | HCA | Clinical clerk | Total | % | |
|---|---|---|---|---|---|---|---|
| I do not like needles | 4 | 1 | 1 | 2 | 3 | 11 | 11.70 |
| I got sick after the vaccine | 24 | 1 | 7 | 5 | 0 | 37 | 39.36 |
| It does not work | 0 | 0 | 0 | 0 | 0 | 0 | 0.00 |
| I never get flu | 5 | 2 | 0 | 2 | 0 | 9 | 9.57 |
| I am vegan | 0 | 0 | 0 | 0 | 0 | 0 | 0.00 |
| It is contraindicated for me | 2 | 0 | 0 | 2 | 0 | 4 | 4.26 |
| It was not offered to me | 0 | 0 | 0 | 1 | 0 | 1 | 1.06 |
| I could not find it | 0 | 0 | 1 | 0 | 0 | 1 | 1.06 |
| I do not believe in the vaccine | 8 | 0 | 0 | 5 | 0 | 13 | 13.83 |
| I do not want to have it |
12 | 2 | 4 | 0 | 0 | 18 | 19.15 |
| Other | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Total | 55 | 6 | 13 | 17 | 3 | 94 | 100.00 |
The questionnaire was given to the HCWs in the inpatient area of an acute London hospital. The HCWs included in the study were doctors, nurses, healthcare assistants (HCA), student nurses and clinical clerks located in the clinical area. HCWs were approached in the clinical area and asked to fill in the questionnaire anonymously. The criteria for inclusion required the HCW to be physically located and working in the clinical area and have patient contact. The questionnaire did not subcategorise by sex or age. There were 306 HCWs that completed the questionnaire during 2019 before the 2019–2020 flu vaccine campaign; 51 doctors completed the questionnaire, 19 student nurses, 182 nurses, 43 HCA and 11 clinical clerks located in the clinical area. The results were collated and statistically analysed using a Pearson’s chi-squared test.
Results
Of the HCWs, 212 (69.28%) had the flu vaccine during the 2018–2019 campaign; 94 (30.62%) did not have the flu vaccine. Only one HCW could not obtain access to the vaccine and only one person was not offered the flu vaccine.
Medical doctors had the highest compliance with 74.41% (38/51) receiving the flu vaccine. Student nurses had 68.42% (13/19) compliance; 69.78% (127/182) of the nurses answered that they received the flu vaccine. Among the clinical clerks, 72.73% (8/11) received the flu vaccine. HCA had the lowest level of compliance with the flu vaccine at 60.47% (26/43). The difference in compliance between doctors and HCA is 14.04%. Although there is a trend to higher uptake with increasing professional qualification (i.e. doctor at 74% vs. HCA at 60%), this was not statistically significant (P = 0.67).
Of the 94 HCWs, the 37 (39.36%) who did not receive the flu vaccine reported that they had a bad reaction once after having the flu vaccine: 18 (19.15%) refused the vaccine because they did not want to receive it; 11 (11.70%) refused the flu vaccine because they do not like needles; 9 (9.57%) answered that their immune system is very strong and they do not need the vaccine; 4 (4.26%) refused the vaccine because it is contraindicated for them; and 13 (13.83%) do not believe in the efficacy of the flu vaccine. Only one HCW wanted the vaccine and could not find it and only one person was not offered the flu vaccine. There was 0% refusal citing concerns about compatibility with a vegan diet or religious reasons.
Discussion
HCWs’ compliance with the flu vaccine in NHS England Trusts during 2018–2019 was 70.3% (PHE, 2019). These results show similar compliance with the average HCWs uptake in NHS England Trusts during 2018–2019. These results in England show higher compliance than other countries in Europe, where compliance of flu vaccine during the 2013–2014 season was 30% among physicians and 11% among nurses (Alicino et al., 2015). Another European country published the results of a cross-sectional survey conducted of HCWs with only 22.1% compliance of the seasonal flu vaccine (Fernández-Villa et al., 2017). During the 2018–2019 flu campaign, the IPC team and occupational health ran an active programme within the inpatient areas offering the flu vaccine and encouraged all HCWs to have the vaccine. Occupational health worked with the IPC team, ward managers and senior leadership to have a large percentage of HCWs immunised. Reminders of the importance of the flu vaccine were announced and disseminated in the daily huddle, intranet, Twitter and emails. A common inaccurate concept is that it is easy to persuade people to get vaccinated; this requires a programme of education, culture change and leadership.
The main reported reason for refusal of the flu vaccine was due to a bad reaction to the flu vaccine on a previous occasion (39.36%). Flu vaccines have been delivered safety for the past 50 years (Centers for Disease Control and Prevention [CDC], 2017a). Flu vaccine for HCWs is manufactured using inactivated (killed) virus, so it cannot cause flu (NHS, 2018a). Therefore, understanding why 12.1% (37/306) of HCWs reported a previous bad reaction to the flu vaccination warrants further investigation.
Vaccination is the best way to reduce the transmission of the influenza virus. The flu vaccine has been demonstrated in different studies to have a historic average of effectiveness of 59% (CDC, 2017b). Despite all the evidence, 9.57% (9/94) of the HCWs reported that they opt out of flu immunisation as they believe that they do not need the flu vaccine and 13.83% (13/94) of HCWs do not believe in the effectiveness of the flu vaccine and therefore refuse to take it. Fear of side effects and doubt in the effectiveness of the vaccine has been described among HCWs in other studies (Petek and Kamnik-Jug, 2018).
Of the 94 HCWs, 4 (4.26%) reported that the flu vaccine is contraindicated for them. One HCW had a cold, two had egg allergies and one had lupus. This may indicate that an educational campaign is required. The NHS website (2018b) indicates that only people with severe egg allergy or acute illness with fever should not take the flu vaccine. However, new egg-free vaccines are available and people with an egg allergy could ask their GP for this. The flu vaccine can also be administrated after an acute illness has resolved and the patient fully recovered. Lupus is not a contraindication for the flu vaccine.
Myths and beliefs about the flu vaccine among HCWs and the community are the main reason of resistance in the flu campaign. Increasing knowledge on flu vaccine side effects could reduce the belief that the flu vaccine can give you flu. The IPC team and occupational health should campaign before and during flu season, increasing knowledge of flu vaccine safety. The biggest impact in compliance would be to target those who believe that the flu vaccine can give you flu. Increasing education surrounding flu vaccination safety will make a profound difference. In the present study, targeting and increasing education to the 37 HCWs that refused the flu vaccine because they got sick once would increase the compliance from 69.28% to 81.3%.
Conclusion
Myths, fears and misinformation are the main barriers for refusal of the flu vaccine. To improve compliance in the hospital environment among HCWs, more information is recommended, and active promotional campaigns should be conducted in the clinical areas, with strong leadership to promote a cultural and behavioural change.
Acknowledgments
The authors thank all HCWs who collaborated and returned the questionnaire.
Footnotes
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Peer review statement: Not commissioned; blind peer-reviewed.
ORCID iD: Mariano Jose Ferragut 
https://orcid.org/0000-0001-6738-6997
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