COVID-19 vaccination refusal and suspension of work among healthy healthcare personnel in Italy: A cross-sectional study of their knowledge and attitudes toward vaccinations

Abstract

Despite the initial optimistic projections from various countries and the evidence that vaccination against coronavirus disease 2019 (COVID-19) reduces the associated hospitalization rates and mortality, vaccine hesitancy and refusal among healthcare personnel (HCP) became a major public health concern globally. The aim of this survey was to estimate the knowledge about the Italian Vaccination Plan for HCP and attitudes about occupational vaccinations for HCP among Italian HCP who refused COVID-19 vaccination and were suspended from work. A total of 52 HCP participated in the study. Nurses were the prevalent profession among vaccination refusers. About COVID-19, 24 (26.2%) of all responders have been involved in COVID-19 care and 21 (40.4%) had a history of COVID-19. None had received influenza and pneumococcus vaccination in the past. Knowledge of vaccinations recommended for HCP was high, ranging from 75% to 98% by vaccine. Instead, all HCP were against any mandatory vaccination policy for all HCP. Finally, most HCP questioned the expected benefits and safety of vaccines in general, raised issues of mistrust of information provided for authorities and of compliance with their HCP’ vaccination recommendations. Our study indicates good knowledge of occupational vaccinations but strong anti-vaccination beliefs among Italian HCP who refused COVID-19 vaccination and were suspended from work.

1. Introduction

From the onset of the coronavirus disease 2019 (COVID-19) pandemic more than two years ago, healthcare personnel (HCP) emerged as a high-risk group for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and occasionally a fatal outcome [1], [2], [3]. From January 2020 to May 2021 3.45 million deaths were reported to the World Health Organization (WHO) globally, while on May 24, 2021 the WHO Director General reported at least 115,000 deaths from COVID-19 among HCP globally [2]. Currently, HCP are still being exposed to SARS-CoV-2.

During the first year of the COVID-19 pandemic there was massive expectancy for COVID-19 vaccines from HCP and the general public. In late 2020 the first COVID-19 vaccines became available and, according to the WHO and other public health authorities, HCP were prioritized for vaccination [4]. COVID-19 vaccines were a key instrument to contain the pandemic and protect HCP. At the end of 2021, it was assessed that the majority (>50 %) of HCP in many developed countries were either completely immunized against COVID-19 or scheduled to get vaccinated [5]. However, despite the initial optimistic projections from various countries and the evidence that COVID-19 vaccination significantly reduces the associated hospitalization rates and mortality, vaccine hesitancy and refusal among HCP became a major public health concern globally [5], [6].

In mid 2021, several countries introduced ad hoc laws for mandatory COVID-19 vaccination of several working groups, including HCP [7]. The rationale for mandatory vaccination policy of HCP was not only to directly protect them and indirectly their patients from healthcare-associated SARS-CoV-2 infection, but also to protect healthcare facilities from outbreaks and HCP absenteeism [8]. Italy was among the first countries to introduce mandatory COVID-19 vaccination for HCP [9]. According to the Italian law, HCP who refused COVID-19 vaccination were suspended from work, without salary and other social security fees, until the legislation will allow them to return without vaccination.

The aim of this survey is estimate the knowledge and attitudes about occupational vaccinations among Italian HCP who refused COVID-19 vaccination and were suspended from work.

2. Methods

This cross-sectional study was prospectively executed between 11 and 25 February 2022 as part of periodic occupational health surveillance and workplace health promotion. A total of 55 HCP working in various hospitals and private clinics of the city of Catania (Italy) were referred to the Occupational Medicine Unit of University of Catania to clarify any scientific doubts that led them to refuse COVID-19 vaccination. HCP were already offered COVID-19 vaccination on-site several times, but persistently refused vaccination because of personal beliefs. HCP were notified concerning the survey aims and gave their consent to participate. The inclusion criteria were: not being eligible for exemption from COVID-19 vaccination on the basis of past medical history, and having been suspended from work because of COVID-19 vaccination refusal. The study was approved by the ethics committee of the University Hospital of Catania (n. 54/2020).

A self-administered multiple-choice questionnaire already used in surveys by our research group [3], [9] was used, following adaptation and validation according to the Adult Vaccine Hesitancy Scale (aVHS) [10]. The questionnaires were compiled by the HCP anonymously and voluntarily and the following data were collected: socio-demographic and employment characteristics, history of vaccination against seasonal influenza and/or pneumococcus, family history of COVID-19 vaccination, having worked in COVID departments, and previous SARS-CoV-2 infection. The latter was evaluated using the COVID-19 score according to the WHO Working Group on the Clinical Characterization and Management of COVID-19 infection [11]. The HCP’ knowledge of vaccines included in the Italian Vaccination Plan for HCP as well as their attitudes toward mandatory vaccinations for HCP were recorded. In addition, ten statements of the aVHS were used to estimate their knowledge and attitudes toward vaccines. The five-point Likert scale which consisted of “strongly agree”, “agree”, “neither agree nor disagree”, “disagree” and “strongly disagree” was used to record their attitudes. According to the Italian Vaccination Plan for HCP, it is recommended that the following vaccines are recommended for HCP are vaccinated against hepatitis B, influenza, measles, mumps, rubella, varicella, and pertussis [12].

Data were analyzed by the software SPSS 22.0 (SPSS Inc., Chicago, IL, USA) for Windows. Multivariate models reporting for clustering by gender, involvement in care of COVID-19 patients, and history of SARS-CoV-2 infection were conducted using linear regression models in vaccine hesitancy scores. Significance was assessed at p-value level of 0.05.

3. Results

A total of 52 out of 55 HCP who refused COVID-19 vaccination and were suspended from work accepted to participate in the survey (response rate: 95 %). Characteristics of participating HCP are detailed in Table 1. Their mean age was 46.73 years. There were 17 males (32.7 %). Nurses were the prevalent profession among vaccination refusers (21 nurses; 40.4 %). Regarding COVID-19, 24 (26.2 %) of all responders have been involved in the provision of healthcare to patients with COVID-19 and 21 (40.4 %) had a history of SARS-CoV-2 infection. The mean COVID-19 score in our study group was 2.95. None of the participants have been vaccinated against seasonal influenza and/or pneumococcus in the past. Most HCP live with family members who have not been vaccinated against COVID-19. Finally, the mean aVHS value of 0.37 indicates high vaccine hesitancy among our study group.

Table 1.

Characteristics of participating HCP.

Variables	N.52
Age (median and 25–75 percentiles)	45.12 (32.63–61.27)
Male gender (n.,%)	17 (32.7 %)
Health care personnel
Physician (n.,%)	8 (15.4 %)
Physiotherapist (n.,%)	6 (11.5 %)
Nurse (n.,%)	21 (40.4)
Midwife (n.,%)	1 (1.9 %)
Dentist (n.,%)	1 (1.9 %)
Radiology technician (n.,%)	3 (5.8 %)
Laboratory technician (n.,%)	4 (7.7 %)
Social health operator (n.,%)	8 (15.4 %)
Education level
Bachelor’s Degree (n.,%)	36 (69.2 %)
Master’s Degree (n.,%)	7 (13.5 %)
Post-graduate specialization (n.,%)	9 (17.3 %)
PhD (n.,%)	0 (0.0 %)
Involvement in COVID-19 care (n.,%)	24 (26.2 %)
Personal history of COVID-19 (n.,%)	21 (40.4 %)
COVID-19 Score (median and 25–75 percentiles)	3.01(2.63–3.42)
Previous influenza vaccination (n.,%)	0 (0.0 %)
Previous pneumococcus vaccination (n.,%)	0 (0.0 %)
Cohabitants vaccinated against COVID-19
Every-one except me (n.,%)	14 (26.9 %)
Some of them (n.,%)	18 (34.6 %)
Nobody (n.,%)	20 (38.5 %)
aVHS (median and 25–75 percentiles)	0.41 (-0.63–1.51)

SD: standard deviation; COVID-19: coronavirus disease 2019; PhD: Doctor of Philosophy; aVHS: Adult Vaccine Hesitancy Scale.

Table 2 summarizes the HCP knowledge regarding the Italian Vaccination Plan for HCP [12] as well as their attitudes toward mandatory vaccinations for all HCP and for HCP who care for immunocompromised patients. Knowledge of vaccinations recommended for HCP was high, ranging from 75 % to 98 % by vaccine. Instead, all HCP were against any mandatory vaccination policyfor all HCP. However, 4 (8 %) and 6 (12 %) of participating HCP were in favor of mandatory vaccinations against seasonal influenza and COVID-19, respectively, for HCP who care for immunocompromised patients. Acceptance rates of mandatory vaccination policies for HCP against other vaccine-preventable diseases were negligible (Table 2).

Table 2.

HCP knowledge of Italian Vaccination Plan for HCP and attitudes toward mandatory vaccinations for HCP.

Vaccine	Correct knowledge*	HCP who favor mandatory vaccinations for All HCP	HCP who favor mandatory vaccinations for HCP who care for immunocompromised patients
Seasonal influenza	50 (96 %)	0 (0 %)	4 (8 %)
Measles	48 (92 %)	0 (0 %)	1 (2 %)
Mumps	47 (90 %)	0 (0 %)	1 (2 %)
Rubella	43 (83 %)	0 (0 %)	1 (2 %)
Varicella	45 (87 %)	0 (0 %)	1 (2 %)
Hepatitis A	39 (75 %)	0 (0 %)	0 (0 %)
Hepatitis B	51 (98 %)	0 (0 %)	0 (0 %)
Pertussis	46 (88 %)	0 (0 %)	1 (2 %)
Tetanus-diphtheria	40 (77 %)	0 (0 %)	1 (2 %)
COVID-19	51 (98 %)	0 (0 %)	6 (12 %)

HCP: healthcare personnel; COVID-19: coronavirus disease 2019.

^*correct knowledge according to the Italian Vaccination Plan for HCP.

When personalized situations were used in the survey, acceptance of mandatory vaccinations was significantly higher among participating HCP, ranging from 54 % to 77 % per situation (Table 3). Table 4 provides HCP responses to the Likert scale of aVHS questions. The participating HCP answers were almost uniformly skewed toward disagreement to statements regarding the benefits and importance of vaccinations an at the same time toward agreement with statements questioning their safety. Finally, 76.9 % of participating HCP do not agree with the statement “The information I receive about vaccines from the Ministry of Health is reliable and trustworthy” while 98 % of them do not comply with their HCP’ recommendations about vaccines.

Table 3.

HCP attitudes regarding mandatory vaccination for HCP using personalized scenarios.

Question	Yes (n.%)
If a member of your family is immunocompromised, should HCP caring for him/her be immune against measles?	37 (71 %)
If your newborn baby is hospitalized, should HCP in the neonatal intensive care unit be immune against varicella?	40 (77 %)
If a member of your family has chronic obstructive pulmonary disease, should HCP caring for him/her be vaccinated against influenza?	28 (54 %)

HCP: healthcare personnel.

Table 4.

Knowledge and attitudes of HCP about vaccines and vaccinations.

aVHS statements	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
Vaccines are important for my health,	0 (0.0 %)	0 (0.0 %)	2 (3.8 %)	42 (80.8 %)	8 (15.4 %)
Vaccines are effective.	0 (0.0 %)	1 (1.9 %)	40 (76.9 %)	7 (13.5 %)	4 (7.7 %)
Being vaccinated is important for the health of others in my community.	0 (0.0 %)	1 (1.9 %)	36 (69.2 %)	10 (23.1 %)	3 (5.8 %)
All routine vaccinations recommended by the Ministry of Health are beneficial.	0 (0.0 %)	1 (1.9 %)	5 (9.6 %)	44 (84.6 %)	2 (3.8 %)
New vaccines carry more risks than older vaccines.	40 (76.9 %)	11 (21.2 %)	1 (1.9 %)	0 (0.0 %)	0 (0.0 %)
The information I receive about vaccines from the Ministry of Health is reliable and trustworthy.	0 (0.0 %)	0 (0.0 %)	12 (23.1 %)	38 (73.1 %)	2 (3.8 %)
Getting vaccinated is a good way to protect me from disease.	0 (0.0 %)	0 (0.0 %)	4 (7.7 %)	40 (76.9 %)	8 (15.4 %)
Generally, I do what my doctor or healthcare provider recommends about vaccines for me.	0 (0.0 %)	0 (0.0 %)	1 (1.9 %)	6 (11.5 %)	45 (86.5 %)
I am concerned about serious adverse effects of vaccines.	39 (75.0 %)	11 (21.2 %)	2 (3.8 %)	0 (0.0 %)	0 (0.0 %)
I do not need vaccines for diseases that are not common anymore.	44 (84.6 %)	7 (13.5 %)	1 (1.9 %)	0 (0.0 %)	0 (0.0 %)

HCP: healthcare personnel; aVHS: Adult Vaccine Hesitancy Scale.

In the multivariable regression models, gender (β: 0.31, p = 0.289), involvement in COVID-19 care (β: 0.37, p = 0.412) and previous history of SARS-CoV-2 infection (β: 0.35, p = 0.540) were not significantly associated with aVHS level.

4. Discussion

This is a cross-sectional survey conducted at the University of Catania (Italy) to investigate the knowledge about occupational vaccinations and attitudes toward mandatory occupational vaccinations among HCP who refused COVID-19 vaccination and were suspended from work. To the best of our knowledge, there are no similar studies published so far.

Italy was the first European country that introduced mandatory COVID-19 vaccination for HCP in order to protect them and their patients, but also to secure healthcare services from HCP absenteeism during periods of high healthcare demand [9]. After Italy, Greece and France were among the first countries globally to render COVID-19 vaccination mandatory for HCP [13], [14].

There is a long debate in Italy and several other countries in Europe and globally, both at a scientific and at a political level about mandatory vaccinations for HCP, considering on one hand their protection, the protection of patients and healthcare systems, and on the other hand the right of HCP to refuse vaccination. In Italy, even before the COVID-19 pandemic, the loss of confidence to vaccinations in the general public but also among HCP was associated with low vaccination coverage rates among them [15]. In fact, low vaccination coverage rates among HCP have been associated with hazardous nosocomial outbreaks of vaccine-preventable diseases, reduced efficiency, and increased absenteeism [16]. In Italy, vaccination rates among employees in long-term care facilities raised even higher [17]. In particular, to August 2021, there are 35.691 HCP without a single dose: the 1.82 % of the total [17]. In French hospitals, from 70.1 % for full vaccination and from 81.3 % for at least one dose [13], while on September 20, 2021, after the sanctions were imposed, vaccination rates were launched to 86.6 % for full vaccination and 92 % for vaccination with at least one dose [13].

In the current study, we found that participating HCP who had refused COVID-19 vaccination and were suspended from work had a good knowledge level about the Italian Vaccination Plan for HCP, ranging from 75 % to 98 % by vaccine, which is high compared to other groups of HCP [4], [8], [18], [19]. Nonetheless, acceptance rates of mandatory vaccinations for HCP were very low in our study group, even for HCP who provide healthcare to immunocompromised patients. Notably, 54 % to 71 % accepted mandatory vaccinations when it concerned their family members, as recorded in the three personalized scenarios, which is significantly lower than in other studies [4], [8], [18], [19]. These findings indicate gaps in their knowledge about the expected benefits of HCP vaccinations for their patients, but also a need to promote the sense of altruism and solidarity toward patients.

The present study showed that almost all HCP who refused COVID-19 vaccination and were suspended from work questioned the safety and efficacy of vaccines and vaccinations in general and therefore believe that they do not need to get vaccinated. Notably, the overwhelming majority of participants had no confidence on authorities, considering them as untrusted sources of information for vaccines and also did not comply with their HCP’ vaccination recommendations [20], [21], [22]. Mandatory vaccination policies for HCP are increasingly adopted and achieve high and sustainable vaccination rates in short term [23], [24].

In our study, none of the participating HCP had been vaccinated against influenza or pneumococcus which indicates a strong anti-vaccination beliefs which is of concern. Comparably, another study found that a history of influenza vaccination was significantly associated with COVID-19 vaccine compliance, while COVID-19 can also influence attitudes toward influenza and pneumococcus vaccines [20], [21], [25].

Another aspect is that the participating HCP refused COVID-19 vaccination despite having worked alongside COVID-19 patients in the past. A previous study had shown that working with COVID-19 patients increased the interest in being vaccinated against COVID-19 [4]. Our finding indicates rather a strong attitude against COVID-19 vaccination, including questioning the expected benefits of the vaccine. The HCP also pointed out that their cohabitants are also mostly unvaccinated, which most likely indicates an overall anti-vaccination culture in their households. It is probable that the participating HCP had an impact on the configuration of negative attitudes toward COVID-19 vaccination in their families.

Despite the study’s novelty, it has some limitations. Firstly, being an ecological study, it has implicit limits. Second, our sample was small, as it included a total of 52 HCP, which could be not representative of HCP refusing COVID-19 vaccination and being suspended from work. A clear strength is the fact that for the first time after the implementation of mandatory COVID-19 vaccination policies for HCP, the knowledge and attitudes toward vaccinations of HCP refusing COVID-19 vaccination and being suspended from work were studied.

In conclusion, the current study provides insights on the knowledge and attitudes toward occupational vaccinations among Italian HCP who refused COVID-19 vaccination and were suspended from work. Our study found a good knowledge level of the Italian Vaccination Plan for HCP. In contrast, mandatory vaccinations were rejected almost universally, with very low acceptance rates concerning COVID-19 and influenza vaccinations of HCP caring for immunocompromised patients. Similarly, all HCP who refused COVID-19 vaccination and were suspended from work had refused influenza and pneumococcus vaccinations in the past, despite good knowledge of national recommendations. Our findings indicate strong anti-vaccination beliefs among HCP who refused COVID-19 vaccination and were suspended from work and should be considered to design interventions to raise COVID-19 vaccination acceptance among HCP. In the meanwhile, mandatory COVID-19 vaccination policies prove valuable to protect HCP, patients and healthcare services during a period of high healthcare demand.

5. Data statement

The data that support the findings of this study are available on request from the corresponding author, [CL]. The data are not publicly available due to [restrictions e.g. their containing information that could compromise the privacy of research participants].

CRediT authorship contribution statement

Caterina Ledda: Conceptualization, Methodology, Validation, Formal analysis, Writing – original draft. Venerando Rapisarda: Investigation, Data curation, Visualization. Helena C. Maltezou: Methodology, Writing – review & editing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.