Journal of Hospital Infection 96 (2017) 268e275

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Influenza vaccine uptake, determinants, motivators,

and barriers of the vaccine receipt among healthcare
workers in a tertiary care hospital in Saudi Arabia
H.K. Haridi a, b, *, K.A. Salman b, E.A. Basaif b, D.K. Al-Skaibi a
a
General Directorate of Health Affairs, Hail Region, Saudi Arabia
b
King Abdulla Medical City, Makkah, Saudi Arabia

A R T I C L E I N F O S U M M A R Y

Article history: Background: Influenza vaccination of healthcare workers (HCWs) is essential for patient
Received 12 December 2016 safety, their own safety, and hospital operation. However, despite its strong recommen-
Accepted 5 February 2017 dation, studies indicates a low rate of vaccine uptake.
Available online 9 February Aim: To assess rates of, and factors affecting, influenza vaccine uptake among HCWs.
2017 Methods: A cross-sectional survey was carried out during October 1st to 16th, 2015, among
HCWs in King Abdullah Medical City in Makkah, Saudi Arabia. A self-administered, anon-
Keywords: ymous questionnaire was distributed to HCWs; this included questions on demographic
Vaccine characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about
Influenza influenza vaccine.
Healthcare workers Findings: Out of 500 HCWs approached, 447 returned valid self-reported questionnaires
Compliance with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination
Barriers during the 2014/15 season, higher than during the 2013/14 (61.2%) and 2012/13 (54.5%)
seasons. Self-protection (81.5%) was the main reason for vaccination, whereas 73.4% of
HCWs reported vaccination to protect patients. The main reasons for vaccination avoid-
ance were misconception that the vaccine causes influenza (38.5%) and concern about
vaccine efficacy (32.7%). Logistic regression analysis revealed that the following were
independently associated with vaccine receipt among HCWs: awareness of vaccine
guidelines; intention to receive the vaccine next season; nurses and other HCWs compared
to physicians; longer practice; and age >40 years.
Conclusion: A good uptake of influenza vaccine was achieved during the 2014/15 season
following adoption of mandatory vaccination policy. Awareness programmes are needed to
correct HCWs’ misconceptions about the vaccine. Efforts need to focus especially on
physicians, younger staff and new recruits.
ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction

Seasonal influenza is an acute viral infection caused by

* Corresponding author. Address: General Directorate of Health influenza viruses; infected individuals are highly contagious
Affairs, Hail Region, P.O. Box, 2510, Hail, 81461, Saudi Arabia.
and can transmit influenza for 24 h before they are symptom-
Tel.: þ96 6507114741.
E-mail address: [email protected] (H.K. Haridi).
atic.1 Influenza causes significant morbidity and mortality;

http://dx.doi.org/10.1016/j.jhin.2017.02.005
0195-6701/ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 269
indeed, on a worldwide basis, influenza as a contributor or influenza.21,22 In response, the Saudi Ministry of Health has
cause of death outpaces all the other vaccine-preventable mandated influenza vaccination for all HCWs in settings
diseases combined. Hospitalized patients are frequently more providing healthcare for pilgrims.
vulnerable to influenza than members of the general Few previously published studies were identified exploring
population.2,3 influenza vaccination among HCWs in healthcare facilities
Healthcare workers (HCWs) can be central to influenza serving Hajj pilgrims.17 Moreover, there is a need to assess the
transmission in hospitals as they are exposed to both infected impact of the recent mandatory vaccination policy. The aims of
patients and patients in high-risk groups.1 Influenza outbreaks this work were to assess the uptake rates of seasonal influenza
in hospitals cause morbidity among patients and HCWs; they vaccine among HCWs, and to identify determinants of
also interfere with normal function of healthcare systems, for compliance with the vaccine uptake and reasons that inhibit or
example by impacting on HCW numbers and workload and on motivate vaccination.
hospital income as a result of fewer elective admissions and
operations.4 Methods
In Saudi Arabia, our hospital in Makkah experienced an
influenza outbreak in January 2016, with 12 confirmed cases of Study design and setting
whom eight were among HCWs.5 An outbreak of influenza A
(H1N1) in a long-term care facility at Taief in 2010 affected 21 The study was a cross-sectional survey carried out between
residents (an attack rate of 47.7%), with two deaths.6 In October 1st and 16th, 2015 among HCWs in King Abdulla Medical
Riyadh, two outbreaks occurred at a tertiary hospital in early City, which is a tertiary care, 550-bed hospital, located in holy
August and late October 2009 with 526 HCWs confirmed H1N1 Makkah, Saudi Arabia. The hospital has more than 3150 staff,
influenza positive.7 Large outbreaks have also been reported in including 574 physicians, more than 900 nurses, and 720 other
other countries. For example, an influenza outbreak in a Jap- HCWs directly involved in patient care. The hospital admitted
anese general hospital in December 2014 affected more than 11,329 inpatients and received 155,204 outpatient visits during
100 individuals (41 patients and 62 staff), with two deaths 2014. Like other hospitals in Saudi Arabia, the hospital provides
among elderly patients.8 influenza vaccine free of charge to all HCWs.
Seasonal influenza vaccination of HCWs is a core component
of infection control policy and patient safety programmes.9,10
Such programmes can reduce patient morbidity and mortal- Subjects
ity, increase patient safety, and reduce work absenteeism
among healthcare workers.11e13 The eligible participants were HCWs who are engaged in
Vaccination coverage among HCWs varies substantially be- direct patient care, including physicians, nurses and other
tween different studies and countries, with lower rates of healthcare workers (pharmacists, laboratory personnel, ther-
uptake mostly reported. In a cross-sectional survey in 27 Eu- apists, technicians, and other staff directly involved in patient
ropean countries vaccination coverage in HCWs ranged be- care.
tween 13% and 89%, with uptake rates in different centres
frequently being <35%, sometimes <25%.13 In the USA, the Sample
Centers for Disease Control and Prevention influenza season
report from 2014/15 showed that 77.3% of all HCWs reported The investigators received a complete list of the eligible
having had an influenza vaccination, an increase of 13.8% HCWs. A representative stratified random sample was taken
compared with the 2010/11 season estimate. This improve- from the eligible population. Sample size was determined
ment in vaccine coverage was attributed mainly to more hos- before study initiation and calculated conservatively to allow
pitals adopting mandatory vaccination policies.14 for maximum sample size, assuming a 50% influenza vaccina-
Influenza vaccine uptake rates among HCWs in Saudi Arabia tion uptake among the respondents with a margin of error of 5%
have previously been reported to be low. In 2014 Alshammari at 95% confidence level. Consequently, a sample of 327 HCWs
et al. reported 38% coverage in six major hospitals, and in 2010 was sought. Anticipating 60e70% response rate, 500 question-
Rehmani and Memon reported 34.4% coverage; both of these naires were distributed taking into consideration a balanced
are substantially better than the 5.9% coverage reported proportion of HCWs according to assignment, departmental
among HCWs employed in Hajj healthcare facilities in affiliations, and work shifts.
2007.15e17 In neighbouring countries, uptake of influenza vac-
cine among HCWs has also been reported to be low: 24.7% in Survey instrument and administration
the Emirates, 46.4% in Oman, 67.2% in Kuwait, and 19.4% in
Qatar.18,19 An anonymous structured questionnaire was constructed
HCWs and healthcare systems have an ethical and moral based on a review of the literature and previous research
duty to protect vulnerable patients from influenza.20 Owing to findings.1,9,16,23,24 The questionnaire included demographic,
the failure of voluntary immunization programmes for HCWs, professional, and work practice characteristics of the re-
mandatory polices are being increasingly adopted by health- spondents; uptake of seasonal influenza vaccine during 2014/
care institutions and public health authorities.9 15, 2013/14, and 2012/13 seasons; vaccine availability, provi-
In Saudi Arabia, healthcare institutions dealing with pilgrims sion of instructions and guidelines; beliefs, attitudes, and
during Hajj seasons provide emergency care for a high-risk concerns about influenza vaccine. Included in the last section,
group of patients, who are predominantly elderly with co- questions sought to assess respondents’ knowledge about
morbid conditions.20 Being exposed to stressful physical con- influenza disease, vaccine facts, and uptake recommenda-
ditions puts them at risk of complicated and/or serious tions. The instrument was reliable for internal consistency with
270 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275
calculated Cronbach’s alpha coefficient at 0.78. The consent- (OR): 2.09; 95% confidence interval (CI): 1.27e3.43; P ¼ 0.004]
ing subjects self-completed the questionnaire after distribu- and for 2012/13 season (61.1% vs 42.4%; OR: 2.14 95% CI:
tion to the eligible HCWs with a briefing for the study 1.31e3.49; P ¼ 0.003). There was no significant difference in
objectives by trained co-ordinators who did not have medical the demographic characteristics of the vaccinated or unvac-
or administrative responsibilities in the hospital during the cinated respondents in 2014/15 season. The mean ages of re-
study. spondents for the two groups were 32.35  7.78 and 32.50 
7.89 years, respectively, and the lengths of practice were 7.46
Pilot study  6.17 and 7.61  6.24 years, respectively (P ¼ 0$185), for the
two groups respectively.
The questionnaire was pre-tested and piloted with a con-
venience sample of 20 HCWs with professional and de- Beliefs, attitudes and concerns about influenza
mographic characteristics similar to those of the study vaccine
population to ensure clarity and ease of administration. Based
on respondents’ recommendations, some changes were incor- Nearly three-quarters of the participants (73.6%) believed
porated to simplify and improve the final questionnaire. that influenza vaccine is valuable in prevention of the disease.
Nurses were more convinced (81.5%) of the vaccine efficacy
Ethics than physicians (64.6%) or other HCWs (71.0%) (P ¼ 0.016). The
majority of participants agreed that they recommended influ-
The Ethical Committee of King Abdulla Medical City enza vaccine to the target groups (81.0%) and to their family
approved the study protocol and the final questionnaire, with members (82.3%). Over half (55.0%) expressed their concern/
approval number 15-216. worry about the vaccine; 38.9% were concerned about the
vaccine efficacy, and 16.1% about vaccine side-effects; there
Statistical analysis was no significant difference between HCWs according to their
employment designations (P ¼ 0.675). Most participants
Statistical analysis was undertaken using the EpiInfo 7 pro- (83.7%) expressed their belief that all HCWs should receive the
gramme. Descriptive statistics were generated for all survey vaccine, 11.6% were uncertain and only 4.7% disagreed. The
items. A binary outcome variable was created to reflect agreement was more pronounced among nurses than physicians
compliance of the subject with seasonal influenza vaccine (91.7% vs 73.7%) with less contradiction (2.1% vs 8.1%). In all,
uptake. A compliant subject was defined as ‘the subject who 83.7% of participants responded that they strongly agreed or
received seasonal influenza vaccine regularly without inter- agreed with the mandatory vaccination policy; 7.4% were un-
ruption for the last three seasons; 2014/15, 2013/14, and 2012/ certain and just 9.0% rated disagree/strongly disagree. Nurses
13’. A bivariate analysis with c2-test and t-test as appropriate were more likely to agree (90.2% strongly agree/agree vs 82.8%
was performed to explore factors associated with HCWs’ for physicians and 76.1% for other HCWs; P ¼ 0.024).
receipt of the vaccine with demographic, professional, and The participants had suboptimal knowledge about influenza
practice characteristics, as well as knowledge and attitude and influenza vaccine, with a mean  SD knowledge score of
towards influenza vaccine. A multivariate logistic regression 16.03  5.86 out of 33 points. There was a significant differ-
model with backward selection and threshold of <0.2 was ence between mean knowledge scores of physicians, nurses,
developed to capture predictors independently associated and other HCWs (17.38  5.53, 16.35  5.76, and 14.73 
with the compliant behaviour of seasonal influenza vaccine 5.971, respectively; P ¼ 0.001); 42.2% of the participants re-
receipt. Odds ratios (ORs) and their 95% confidence intervals ported themselves that they had insufficient knowledge about
(CIs) were reported as measures of association between pre- the vaccine.
dictors and outcome of interest. All statistical tests were two-
tailed and P  0.05 was considered statistically significant. Variables associated with respondents’ vaccination
uptake
Results
The potential predictors for compliance of seasonal influ-
Respondent data and influenza vaccine uptake enza vaccine uptake were examined on the basis of the
compliance definition postulated in the present study as the
In all, 447 of the 500 questionnaires that were distributed subject who received seasonal influenza vaccine regularly
were returned (response rate 89.4%). Respondents were com- without interruption for the last three seasons: 2014/15, 2013/
parable to the surveyed population (P ¼ 0.207). The charac- 14, and 2012/13).
teristics of the respondents are summarized in Table I. Table II presents the results of logistic regression analysis. In
Overall, 394/447 (88.3%) of the respondents reported the univariate logistic regression analysis with the potential
receiving a vaccination in the 2014/15 season, higher than in predictors we found that nurses were significantly more
the 2013/14 season (61.2%, 273/447) and in the 2012/13 season compliant to receive vaccination regularly than were physi-
(54.5%, 243/447) (Figure 1). cians (OR: 2.29; 95% CI: 1.37e3.84; P < 0.01); respondents with
Uptake was significantly higher in the last season (2014/15) longer length of practice (5e9 years) compared to those with
among nurses (93.3%) compared to physicians (86.9%) and other <5 years practice (1.80; 1.15e2.83; P < 0.05); intention to
health professionals (83.1%) (P ¼ 0.012). For the previous receive the vaccine next season (5.02; 2.32e10.87; P < 0.001);
seasons, nurses also had higher vaccine uptake compared to reading Ministry of Health vaccine circulars/guidelines (2.47;
physicians for the 2013/14 season [68.9% vs 51.5%; odds ratio 1.67e3.63; P < 0.001); self-efficacy of having sufficient
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 271

Table I
Characteristics of the participants, influenza vaccination and knowledge score among 447 healthcare workers (HCWs) in King Abdulla
Medical City, Makkah, KSA, 2015
Overall Vaccination status 2014/2015 season P
Vaccinated Unvaccinated
Assignment 0.0121
Physician 99 (22.1%) 86 (86.9%) 13 (13.1%)
Nurse 193 (43.2%) 180 (93.3%) 13 (6.7%)
Other HCWs 155 (34.7%) 128 (83.1%) 26 (16.9%)
Gender 0.160
Male 221 (49.4%) 200 (90.5%) 21 (9.5%)
Female 226 (50.6%) 194 (86.2%) 31 (13.8%)
Age (years) 0.125
25 53 (11.9%) 46 (86.8%) 7 (13.2%)
26e30 197 (44.1%) 174 (88.8%) 22 (11.2%)
31e35 80 (17.9%) 65 (81.3%) 15 (18.8%)
36e40 62 (13.9%) 59 (95.2%) 3 (4.8%)
>40 55 (12.3%) 50 (90.9%) 5 (9.1%)
Median (mean  SD) 30 (32.35  7.78) 30 (32.50  7.89) 29 (31.29  6.96) 0.294
Education (highest degree) 0.290
Less than Bachelor 27 (6.0%) 22 (81.5%) 5 (18.5%)
Bachelor 262 (58.6%) 235 (90.0%) 26 (10.0%)
Postgraduate (Diploma/Master) 80 (17.9%) 67 (83.8%) 13 (16.3%)
Postgraduate (Board/PhD/MD) 78 (17.4%) 70 (89.7%) 8 (10.3%)
Length of practice (years) 0.384
<5 168 (37.6%) 143 (85.6%) 24 (914.4%)
5e9 152 (34.0%) 137 (90.1%) 15 (9.9%)
10 127 (28.4%) 114 (89.8%) 13 (10.2%)
Median (mean  SD) 6 (7.46  6.17) 6 (7.61  6.24) 5 (6.40  5.54) 0.185
Marital status 0.099
Single 169 (37.8%) 147 (87.5%) 21 (12.5%)
Married 269 (60.2%) 241 (89.6%) 28 (10.4%)
Others (divorced, widowed) 9 (2.0%) 6 (66.7%) 3 (33.3%)
Have children aged <16 years
Yes 179 (40.0%) 162 (90.5%) 17 (9.5%) 0.244
No 268 (60.0%) 232 (86.9%) 35 (13.1%)
Have any chronic disease 0.181
No 385 (85.9%) 337 (87.5%) 48 (12.5%)
Yes 63 (14.1%) 57 (93.4%) 4 (6.6%)
Vaccinated 2013/2014 season 0.003
Yes 273 (61.2%) 251 (63.7%) 22 (42.3%)
No 173 (38.8%) 143 (36.3%) 30 (57.7%)
Vaccinated 2012/2013 season 0.014
Yes 243(54.5%) 223 (56.6%) 20 (38.5%)
No 203 (45.5%) 171 (43.4%) 32 (61.5%)
Intend to receive the vaccine next season
Yes 383 (86.8%) 353 (90.5%) 37 (9.5%) <0.001
No 58 (13.2%) 30 (58.8%) 21 (41.2%)
Knowledge score about influenza and vaccine 16 (16.03  5.86) 16 (15.80  5.98) 16 (15.80  5.98) 0.315
[median (mean  SD)]
HCWs, healthcare workers.

knowledge about the vaccine (1.63; 1.11e2.41; P < 0.05); reading Ministry of Health influenza vaccine circulars/guide-
recommending the vaccine to family members (1.95; lines (OR: 1.94; 95% CI: 1.29e2.93; P < 0.01) and intention to
1.14e3.33; P < 0.05); and participants’ agreement with regard receive the vaccine next season (4.45; 2.00e9.91; P < 0.001).
to mandating vaccination for all HCWs. Compared to physicians, nurses (3.54; 1.76e7.71; P < 0.01) and
In the multivariate logistic regression analysis intended to other HCWs (2.65; 1.30e5.40; P < 0.01), longer length of
capture predictors that were independently associated with practice (5e9 years) compared to those with <5 years’ practice
the compliance of vaccine uptake, the model identified (1.85; 1.14-3.00; P < 0.05), and age >40 years (2.69;
272 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275

2014/2015 2013/2014 2012/2013

100
93.3
90 88.3 86.9
83.1
Influenza vaccine uptake (%)

80
68.9
70
61.2 61.1
60 57.8
54.5 53.9
51.5
50
42.4
40
30

20
10
0
Overall Physicians Nurses Other HCWs

Figure 1. Influenza vaccine uptake (%) for influenza vaccination seasons 2014/15, 2013/14 and 2012/13 among healthcare workers
(HCWs) in King Abdulla Medical City, Makkah, Saudi Arabia.

Table II
Logistic regression analysis of demographic, professional, and institutional factors associated with compliance with seasonal influenza
vaccine uptake among 447 healthcare workers in King Abdulla Medical City, Makkah, KSA, 2015
Variables Vaccination compliancea Univariate OR (95% CI) Adjusted OR (95% CI)
No Yes
Assignment
Physicians 70 (70.7%) 29 (29.3%) 1 1
Nurses 99 (51.3%) 94 (48.7%) 2.29 (1.37e3.84)** 3.54 (1.76e7.12)**
Other HCWs 96 (61.9%) 59 (38.1%) 1.48 (0.86e2.55) 2.65 (1.30e5.40)**
Gender
Male 133 (60.2%) 88 (39.8%) 1
Female 132 (58.4%) 94 (41.6%) 1.08 (0.74e1.57)
Age (years)
<40 229 (61.2%) 145 (38.8%) 1 1
40 36 (49.3%) 37 (50.7%) 1.62 (0.98e2.69) 2.69 (1.30e5.58)**
Length of practice in years
<5 112 (66.7%) 56 (33.3%) 1 1
<5e9 80 (52.6%) 72 (47.4%) 1.80 (1.15e2.83)* 1.85 (1.14e3.00)*
10 73 (57.5%) 54 (42.5%) 1.48 (0.92e2.38) 1.56 (0.86e2.84)
Marital status
Single 108 (63.9%) 61 (36.1%) 1
Married/Others 157 (56.5%) 121 (43.5%) 1.37 (0.92e2.02)
Education (highest)
Less than Bachelor 20 (74.1%) 7 (25.9%) 1
Bachelor 142 (54.2%) 120 (45.8%) 2.42 (0.99e5.90)
Postgraduate degree 103 (65.2%) 55 (34.8%) 1.53 (0.61e3.83)
Have a chronic medical condition
No 233 (60.5%) 152 (39.5%) 1
Yes 33 (52.4%) 30 (47.6%) 1.39 (0.82e2.38)
Have children aged <16 years
No 163 (60.8%) 105 (39.2%) 1
Yes 102 (57.0%) 77 (43.0%) 0.85 (0.58e1.25)
Intend to receive the vaccine next season
No 50 (86.2%) 8 (13.8%) 1 1
Yes 213 (55.5%) 171 (44.5%) 5.02 (2.32e10.87)*** 4.45 (2.00e9.91)***
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 273

Table II (continued )
Variables Vaccination compliancea Univariate OR (95% CI) Adjusted OR (95% CI)
No Yes
The vaccine is available at my workplace all the time
No 89 (63.1%) 52 (36.9%) 1
Yes 172 (57.3%) 128 (42.7%) 1.27 (0.84e1.93)
Read/offered Ministry of Health circular/guidelines
No 170 (68.8%) 77 (31.2%) 1 1
Yes 94 (47.2%) 105 (52.8%) 2.47 (1.67e3.63)*** 1.94 (1.29e2.93)**
Feel have sufficient vaccine knowledge
No 124 (66.0%) 64 (34.0%) 1
Yes 140 (54.3%) 118 (45.7%) 1.63 (1.11e2.41)*
Believe the vaccine is valuable in influenza prevention
No 75 (64.1%) 42 (35.9%) 1
Yes 189 (57.8%) 138 (42.2%) 1.30 (0.84e2.02)
I recommend the vaccine to the target groups
No 56 (65.9%) 29 (34.1%) 1
Yes 209 (57.7%) 153 (42.3%) 1.41 (0.86e2.32)
I recommend the vaccine to my family members
No 56 (71.8%) 22 (28.2%) 1
Yes 209 (56.6%) 160 (43.4%) 1.95 (1.14e3.33%)*
All HCWs should receive the vaccine (agreement)
Uncertain/Not agree/Strongly disagree 51 (69.9%) 22 (30.1%) 1
Strongly agree/Agree 214 (57.2%) 160 (42.8%) 1.73 (1.01e2.98%)*
I have concern about the vaccine side-effects or efficacy
No 119 (59.2%) 82 (40.8%) 1
Yes 146 (59.3%) 100 (40.7%) 0.99 (0.68e1.45)
Knowledge of influenza disease 16 (15.80  5.98) 16 (16.37  5.66) 1.07 (0.98e1.05)
and vaccine score (out of 32 points)
[median (mean  SD)]
OR, odds ratio; CI, confidence interval; HCWs, healthcare workers.
*P < 0.05; **P < 0.01; ***P < 0.001.
Final model: e2*log-likelihood: 534.09; interactions: 5; c2 ¼ 55.80; df: 7; P < 0.001.
a
Received vaccination in the last three seasons.

1.30e5.58; P < 0.01) were factors independently associated located in holy Makkah, Saudi Arabia, that opened in 2010. The
with vaccine uptake. hospital serves pilgrims among other patients during Hajj and
Omra seasons for Muslims, which host the largest annual mass
gatherings of people in the world.
Reasons for acceptance or avoidance to receive
In the first two years after the hospital opened, vaccine
seasonal influenza vaccine uptake by HCWs was low (23e29%), despite the vaccine being
strongly recommended and provided free of charge. Subse-
Table III presents the most frequent reasons cited by the
quently, campaigns were implemented every season to
respondents for having or not having seasonal influenza vac-
encourage staff to accept vaccination including awareness
cine. The most cited reasons for being vaccinated were: self-
sessions and easy accessibility to the vaccine. These campaigns
protection (81.5%), to protect patients (74.4%), as an institu-
at best merely convinced only half of the staff to be
tional requirement (55.6%), to prevent cross-infection (45.7%),
vaccinated.
and having contact with household children (32.2%). The most
In response to low rates of voluntary uptake of influenza
cited reasons for not getting the vaccine were: the miscon-
vaccine by HCWs, and the high vulnerability of many pilgrims
ception that the vaccine causes influenza (38.5%), concerns
during the Hajj seasons, in 2013 the Ministry of Health in Saudi
about vaccine efficacy (32.7%), trust in/wish to challenge
Arabia adopted a mandatory vaccination policy for HCWs in all
natural immunity (21.2%), the vaccine was not available
healthcare facilities in Makkah and Madinah. The aim was to
(11.5%), not all strains of the virus are covered (9.6%), and
ensure an acceptable level of vaccination to ensure patient
experience of severe localized reaction in previous vaccination
safety and prevent any impact on hospital activities.2 There
(9.6%).
were no penalties for unvaccinated staff. The observed effect
size of this change in policy was modest, vaccination coverage
Discussion increasing only by 6.7%, from 54.5% in 2012/13 to 61.2%. In the
following season, 2014/15 (the year of the study), mandatory
Our study was a cross-sectional survey among healthcare vaccination was associated with a consequence of not
workers in King Abdulla Medical City, a tertiary care hospital, permitting the unvaccinated staff to participate in the Hajj
274 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275

Table III studies which showed that intention to be vaccinated is a good

Most frequent reasons cited by healthcare workers for accepting or predictor of the behaviour to get vaccinated.33
declining to receive seasonal influenza vaccine in King Abdulla In contrast with several previous studies that have reported
Medical City, Holy Makkah, 2015 that influenza vaccination uptake is higher among physicians
than among other HCWs e including nurses24 e physicians in
Reasons for vaccine uptake or avoidance Frequencya
our study were less likely to voluntarily get vaccinated
Uptake (N ¼ 394) compared to nurses and other HCWs. Consistent with other
Protect myself 321 (81.5%) studies, older age (>40 years) was independently associated
Protect patients 293 (74.4%) with voluntary influenza vaccine uptake in our study.23,24,31
Required by my institution 219 (55.6%) This could be explained by old age being a risk factor for
Prevent cross-infection 180 (45.7%) influenza complications and chronic disease onset. Longer
Having children contact at home 127 (32.2%) duration of practice in our study was also found to be an in-
Avoidance (N ¼ 52) dependent predictor of influenza vaccination uptake, which
Vaccine causes influenza 20 (38.5%) could be explained by superior professional experience and
Concern about vaccine efficacy 17 (32.7%) scientific knowledge, thus becoming more aware of the
Trust in/wish to challenge my natural immunity 11 (21.2%) increased risk of the disease and more convinced of the vaccine
The vaccine was not available 6 (11.5%) efficacy.
Not all stains are covered 5 (9.6%) The most frequent motivating reasons cited by HCWs of
Prior experience of severe localize reaction 5 (9.6%) getting vaccinated in our study were dominated by ‘self-pro-
a
A respondent could mention more than one reason. tection’ (81.5%), which other studies have noted, followed by
‘patient protection’ (74.4%).18,23 This imply the importance to
focus attention of HCWs on the top priority of culture of patient
programme in which participants receive a financial and non- safety. Other cited motivating factors to receive the vaccine
financial incentives. A good coverage rate (88.3%) was ach- were: ‘required by my institution’, ‘prevent cross-infection’
ieved, with an increase of 33.8% compared to the 2012/13 and ‘having children contact at home’; these motivating fac-
season before adoption of this strategy, a coverage rate tors that influenced HCWs’ decision to take influenza vaccine
approaching US standards (90%) and exceeding the EU goal were also demonstrated by other studies.11,16,19,23 On the other
(75%).25,26 This strategy was shown to be effective in other hand, concerns about the vaccine efficacy and side effects
reports and to have a rational and ethical justification.14,27e30 were the most important reasons cited by the participants for
The mandatory vaccination policy in the last season 2014/ vaccination avoidance; a findings consistent with prior
2015, masked almost all predictors of voluntary vaccination research.15,16,18,19,23,24
found in the previous seasons, which entail that this approach The large sample size, high response rate, accurate repre-
defeated the barriers of suboptimal vaccination among HCWs. sentation of the hospital HCWs, and the large number of items
However, relying on mandatory vaccination policy to reach a explored through the questionnaire represent strengths of our
satisfactory level of influenza vaccine uptake among HCWs study. The cross-sectional nature of the study design, HCWs’
does not eliminate the need to understand and deal with fac- self-reporting of vaccine uptake which was not cross-checked
tors that enhances voluntary vaccine uptake. with records due to anonymity of the questionnaire, and
As seen from our results, despite the good vaccine coverage possible recall bias are the main limitations.
triggered by the mandatory vaccination policy, important In conclusion, our results show a good uptake of seasonal
misconceptions and inadequate knowledge about influenza influenza vaccine during the 2014/15 season, after adoption of
vaccine remained. Moreover, a considerable number of HCWs mandatory vaccination policy.
also had concerns about the vaccine efficacy and side-effects, Awareness programmes are needed to supply evidence-
as in previous research.16,23 Thus orientation programmes may based information about nosocomial influenza and influenza
be crucial to correct misconceptions and close the knowledge vaccine guidelines, and to address concerns about vaccine ef-
gap of the HCWs. ficacy and side-effects. It may be of value to focus efforts on
Good knowledge about influenza vaccine is not only impor- HCWs who are less compliant to receive vaccination, especially
tant for sustaining good vaccine uptake, but is also important younger HCWs and physicians.
for commitment of the HCWs to prescribe the vaccine to the Based on large effect size, high acceptance, and minimal
vulnerable target groups of patients and high-risk people. contradiction, we recommend extension of mandatory vacci-
Vaccination of physicians together with their opinions on the nation policy to other health facilities.
effectiveness of the vaccine was a predictor of vaccination
coverage in their patients.31,32
Our study also examined the potential predictors of volun-
tary influenza vaccination among HCWs. Awareness of HCWs Acknowledgement
with influenza vaccine guidelines was an independent driver
for vaccination (OR: 1.94; P < 0.01), which implies the We thank the study participants, who devoted their time to
importance of supplying HCWs with evidence-based guidelines give valuable information.
and ensuring that these guidelines are accessed and
comprehended. Conflict of interest statement
A major independent driver for the voluntary vaccine up- None declared. The views in this paper are the personal
take was the intention to receive the vaccine next season (OR: views of the authors and do not necessarily represent the
4.45; P < 0.001). This finding supports the results of other views of the institutions of which we are members.
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 275
Funding sources 16. Rehmani R, Memon JI. Knowledge, attitudes and beliefs regarding
None. influenza vaccination among healthcare workers in a Saudi hos-
pital. Vaccine 2010;28:4283e4287.
17. Madani TA, Ghabrah TM. Meningococcal, influenza virus, and
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