Attitudes, beliefs and practice of Egyptian healthcare workers towards seasonal influenza vaccination

Abstract Background Seasonal influenza vaccination is highly recommended for healthcare workers (HCWs) every year to protect them and reduce the risk of disease transmission at workplaces. Relatively few studies addressed influenza vaccination in the Eastern Mediterranean Region. Objectives The main objective of this study was to explore the attitudes, beliefs and practice of Egyptian HCWs towards seasonal influenza vaccine. Methods This is a nationwide cross‐sectional study. Data were collected through self‐administered structured questionnaire. A sample of 3534 HCWs (physicians and nurses) was collected from different levels of healthcare facilities. Results The proportion of seasonal influenza vaccine uptake during the last season was 30.7% while the percentage of ever vaccinated was 46.8%. The most identified reason for non‐compliance was lack of trust about vaccine efficacy and its adverse events. Around 80% of participants expressed positive attitude towards influenza vaccine and the vast majority (98%) agreed to uptake the vaccine during pandemic. There was significant positive association between attitude score and influenza vaccine uptake. Raising awareness about vaccine and ensuring vaccine availability were the main suggestions by HCWs to improve vaccine uptake. Conclusions Although there was positive attitude towards influenza vaccine, yet vaccination coverage was suboptimal particularly among those working in university hospitals. Educational messages and operational strategies addressing motivators and barriers that emerged from this study are needed to optimize vaccine uptake.


| INTRODUC TI ON
Globally, annual influenza vaccination rates among healthcare workers (HCWs) are almost low despite recommendations from WHO and national public health institutions of many countries. 1 Unvaccinated HCWs are an important source of nosocomial influenza. Transmission of influenza virus from patients to HCWs, from HCWs to patients and among HCWs has been well documented. 2,3 The possible consequences of infected HCWs include increased morbidity and mortality among patients at risk of contracting influenza and a high rate of sickness absenteeism among HCWs themselves resulting in shortage of staff, additional burden on the health system and reduce the healthcare quality. 4,5 Influenza vaccination is the most effective strategy for the prevention of influenza virus infection and the potentially severe complications. The World Health Organization (WHO) and the Advisory Committee on Immunization Practices (ACIP) recommend that HCWs should be vaccinated annually against influenza. It is also recommended that healthcare organizations implement policies and procedures to encourage HCWs vaccination. 3 Ahmed and colleagues found that vaccination of HCWs significantly reduced influenza-like illness and all-cause mortality among patients. 5 Relatively, few studies addressed influenza vaccination in the Eastern Mediterranean Region. 6 In a study among HCWs in three Middle East countries, the vaccination rate was 24.7%, 67.2% and 46.4% in United Arab Emirates, Kuwait and Oman, respectively. Moreover, the different variables associated with the noncompliance of HCWs to the annual influenza vaccination were lack of time (31.8%) followed by unawareness of vaccine availability (29.4%), unavailability of vaccine (25.4%), doubts about vaccine efficacy (24.9%), lack of information about importance (20.1%) and concerns about its side effects (17.3%). 7 Recent WHO Strategic Advisory Group of Experts (SAGE) on Immunization for influenza vaccination recommended HCWs as one of the highest priority groups for receipt of influenza vaccines during the current COVID-19 pandemic. 8 To our knowledge, this is the first study among HCWs in Egypt tackling influenza vaccination. The purpose of the present nationwide study is to explore attitudes, beliefs and practice of HCWs in Egypt regarding seasonal influenza vaccination. The ultimate goal is to gather data to plan future interventions and policies aiming at increasing influenza vaccination coverage among Egyptian HCWs.

| Study settings
A nationwide cross-sectional study was conducted between June and October 2019 in 11 governorates representing different country regions. From Middle region, both Cairo and Giza governorates were selected purposively as they include all types of healthcare services and large number of HCWs. From South region, three governorates were randomly selected: Fayoum, Menia and Assiut. From North region, 5 governorates were randomly selected: Qalyoubia, Gharbia, Menoufia, Sharkia and Alexandria while one governorate was selected from Suez Canal zone (Port Saied).
From each selected governorate, the capital city was purposively included to ensure the representation of all healthcare service levels provided by MOHP, in addition to the university hospitals.

| Study participants
Physicians and nurses of the selected healthcare facilities were asked to participate in the study. Many specialties were included in the study particularly those working in Intensive Care Units (ICU), Neonatal Intensive Care Units (NICU), chest hospitals and fever hospitals. Also, HCWs in the departments of internal medicine, paediatrics and primary health care were represented in the sample.
Eligible subjects were physicians and nurses providing health care to patients, while those with no or minimal contact with patients and those with less than 1-year in-job experience were excluded.

| Sample size determination
Sample size was calculated using influenza vaccine uptake of 28.2% as estimated in Eastern Mediterranean regions, 6 using 95% confidence level and 5% margin error. During calculation, we considered the average number of HCWs (physicians and nurses) per governorate = 12 000. Accordingly, the sample size required was 303 HCWs.
As the study was conducted in 11 governorates, the total sample size required was =303 × 11 = 3333 HCWs. Using an estimated response rate of 90%, the required sample increased to 3703. Sample size was calculated by the software program Epi Info version 7.0 for Windows. CDC -Atlanta, USA. 9

| Study tool
A structured self-administered questionnaire was designed to be distributed to target study subjects at their workplaces. The questionnaire included selected socio-demographics information, in addition to questions on HCWs beliefs, attitudes and practice regarding seasonal influenza vaccination.

| 779
The tool was piloted and revised based on the answers of 60 HCWs (30 physicians and 30 nurses). Reliability and validity of the tool were assessed by experts in public health and epidemiology before distribution (Cronbach's Alpha was 0.83). Data collectors and field supervisors were trained before starting field visits to healthcare facilities.

| Data management and statistical analysis
The data were reviewed for completeness and consistency. Double

| Vaccination status
Of 3534 respondents, 1653 (46.8%) reported having influenza vaccine at least one time, 342/1653 (20.7%) mentioned they had it once and around 40% gave history of 2 to 4 times uptake of the vaccine (Table 2).
Among those who had ever been vaccinated, the main reasons for vaccination were as follows: vaccine is effective and safe (70.2%), it prevents influenza (34.1%), is free of charge (30.6%) and HCWs are at risk of getting influenza infection (25.0%) ( Figure 1).
While among those who did not get the vaccine during the last season, the main reasons not to get vaccinated were as follows: vaccine is ineffective (28.5%), it causes complications and adverse events (25.1%), and vaccine expenses (18.9%) ( Figure 2).

| HCWs beliefs and attitude towards influenza vaccination
Although 1292 (36.6%) think that the vaccine is effective in preven-  Figure 3).

| Predictors of influenza vaccination in HCWs
Overall, 1085 (30.7%) had been vaccinated in the last season (  Table 6).
The most common suggestions raised by participants to improve the coverage rate of influenza vaccine uptake among healthcare professionals were health education about influenza vaccine particularly about efficacy and safety was mentioned by 27.3% of the respondents followed by availability of the vaccine at work (21.9%).

Other suggestions included mandatory influenza vaccination for all
HCWs (11.6%) and offering vaccine free of charge or inexpensive/ reasonably priced (9.6%) ( Figure 4).

| DISCUSS ION
The present study is the first study to estimate influenza vaccination coverage among Egyptian HCWs and explore their beliefs and attitudes towards seasonal influenza vaccination to improve vaccination coverage among them.
The current study demonstrates a vaccination ever uptake rate among HCWs equal to 46.8% and about 31% in the last season prior to the study. These rates are higher than that reported from EMR (28.2%), 6 UAE (24.7%), 7 India (4.4%), 3 China (6.8%) 10 and Pakistan (8.84%), 11 while they are lower than the vaccination uptake among HCWs in Saudi Arabia (67.6%), 12 and the rates (60% and 80%) reported from developed countries. [13][14][15][16] The reasons for lower vaccination rate in developing countries could include lack of national vaccination strategies, level of awareness of HCWs towards influenza vaccination and the vaccine cost.
This could be supported by the higher vaccination rate encountered F I G U R E 2 Reasons for rejecting uptake of influenza vaccine among HCWs among physicians. 13 We may relate our results to the higher positive attitude among nurses than physicians. Other studies from Saudi Arabia, Australia and Ireland revealed no significant differences in vaccination coverage among the different professions. 12,15,26 Higher rates of vaccine coverage were found among staff working in related hospitals (such as chest/fever and infectious diseases hospitals) and specialty (such as chest/tropical and infectious diseases

| Strengths and limitations
The strengths of our study are related to the appropriate sample size

| CON CLUS ION AND RECOMMENDATIONS
In conclusion, influenza vaccine coverage is suboptimal among HCWs in Egypt. Low rates stem from a variety of reasons ranging from inadequacy of knowledge to misperceptions and fears regarding vaccine efficacy and safety, in addition to high cost and unavailability. These findings should be used to customize and improve any future promotion campaigns, in order to overcome the identified barriers. Also, operational strategies addressing vaccination accessibility at workplace need to be implemented to improve vaccine uptake.
Participants in this study were mostly having positive attitudes and beliefs towards influenza vaccine, and this provides better opportunity to improve vaccine coverage through the tailored health education campaigns and operational strategies which hinder the barriers that limit compliance to vaccination.

ACK N OWLED G EM ENT
The authors cordially acknowledge all HCWs who participated in this study. We thank all team staff who supervised the data collection.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author after permission from relevant authority to release data and upon reasonable request.