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Hoskins A, Worth LJ, Malloy MJ, Walker K, Bull A, Bennett N. Hepatitis B immune status of staff in smaller acute healthcare facilities. AUST HEALTH REV 2023; 47:254-257. [PMID: 36877980 DOI: 10.1071/ah22219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/09/2023] [Indexed: 03/08/2023]
Abstract
ObjectiveTo determine the proportion of staff employed in smaller Victorian public acute healthcare facilities with evidence of immunity to hepatitis B.MethodsFor optimal long-term immunity, a completed hepatitis B vaccination course and post vaccination hepatitis B surface antibody (anti-HBs) level ≥10 mIU/mL is desirable for all high-risk staff employed in healthcare facilities. For the financial years 2016/17-2019/20, a standardised surveillance module developed by the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre was completed by the smaller Victorian public acute healthcare facilities (individual hospitals with <100 acute care beds or their multi-site health service). Staff were assessed as having evidence or no evidence of optimal immunity to hepatitis B. Those without optimal evidence were sub-classified as 'incomplete vaccination course', 'no serology', 'contraindicated', 'non-responder', 'declined' or 'unknown'. Data were analysed to determine trends over time for healthcare facilities that participated more than once.ResultsA total of 88 healthcare facilities reported hepatitis B immunity status of high-risk (Category A) staff (n = 29 920) at least once over 5 years; 55 healthcare facilities reported more than once. The aggregate proportion with evidence of optimal immunity was 66.3%. Healthcare facilities with 100-199 Category A staff employed reported the lowest evidence of optimal immunity (59.6%). Of all Category A staff with no evidence of optimal immunity, the majority had 'unknown' status (19.8%), with only 0.6% overall who declined vaccination.ConclusionsOur study found evidence of optimal staff hepatitis B immunity in only two-thirds of Category A staff working in surveyed healthcare facilities.
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Affiliation(s)
- Alex Hoskins
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia
| | - Leon James Worth
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia; and Department of Medicine, University of Melbourne, Melbourne, Vic. 3065, Australia
| | - Michael James Malloy
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia
| | - Katherine Walker
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia
| | - Ann Bull
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia
| | - Noleen Bennett
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute for Infection and Immunity, Melbourne, Vic. 3000, Australia; and Department of Nursing, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Vic. 3065, Australia
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A Wide Range of Strategies to Cope with Healthcare Workers' Vaccine Hesitancy in A North-Eastern Italian Region: Are They Enough? Healthcare (Basel) 2020; 9:healthcare9010004. [PMID: 33374510 PMCID: PMC7822214 DOI: 10.3390/healthcare9010004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 01/01/2023] Open
Abstract
The recent pandemic reminded the world of the high risk of healthcare workers (HCWs) and patient contagiousness along with the healthcare services disruption related to nosocomial outbreaks. This study aims at describing vaccination campaigns within healthcare institutions of a North-Italian Region and comparing their effectiveness in term of vaccination coverage. In December 2019, we surveyed all healthcare institutions of Friuli Venezia Giulia Region throughout an email questionnaire with 15 questions investigating strategies adopted for the vaccination of HCWs against influenza and other vaccine-preventable diseases (VPDs), along with actions put in place in case of a VPD exposure. We found a strong heterogeneity in VPDs prevention and control policy and practice for HCWs, along with responsibility attribution ranging among different stakeholders. Strategies adopted to promote vaccination included a wide range of methods, but HCWs' influenza vaccination coverage still ranged from 17.0 to 33.3%. Contact tracing after a VPD exposure did not always include medical residents and students and visitors/caregivers/extra personnel as possible contacts. Even if knowledge and complacency gaps among HCWs could be faced with education activities, more efforts should be done in identifying and implementing effective vaccination strategies, and mandatory vaccination for HCWs could be introduced to achieve host, herd, and healthcare immunity preventing possible hospital outbreaks.
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Bennett N, Sutton B, Strachan J, Hoskins A, Malloy MJ, Worth LJ. Measles immunisation status of healthcare workers in smaller Victorian hospitals: can we do better? Aust N Z J Public Health 2020; 44:346-348. [DOI: 10.1111/1753-6405.12989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/01/2020] [Accepted: 03/01/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Noleen Bennett
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Doherty Institute for Infection and Immunity Victoria
- Department of Nursing, Melbourne School of Health Sciences The University of Melbourne Victoria
| | - Brett Sutton
- Department of Health and Human Services Victorian State Government
| | - Janet Strachan
- Department of Health and Human Services Victorian State Government
| | - Alex Hoskins
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Doherty Institute for Infection and Immunity Victoria
| | - Michael J. Malloy
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Doherty Institute for Infection and Immunity Victoria
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health The University of Melbourne Victoria
| | - Leon J. Worth
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Doherty Institute for Infection and Immunity Victoria
- Department of Medicine The University of Melbourne Victoria
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Vrachnaki O, Vergadi E, Ioannidou E, Galanakis E. Determinants of low uptake of vaccination against influenza, measles, and hepatitis B among healthcare professionals in Greece: a multicenter cross-sectional study. Hum Vaccin Immunother 2020; 16:2663-2669. [PMID: 32401656 DOI: 10.1080/21645515.2020.1741311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Vaccination is recommended for healthcare professionals (HCPs) to protect them against vaccine-preventable diseases (VPDs); however, uptake rates are low. This study aimed to evaluate HCPs' influenza, hepatitis B, and measles vaccine uptake in all healthcare levels in Crete, Greece. We conducted a questionnaire-based, cross-sectional multicenter study in 2018, including HCPs employed at 18 primary care centers and 3 hospitals. Overall, 2,246 HCPs responded (57.2% of the target population). The influenza vaccine uptake rate was 36.1% (810/2,246), with the annual vaccination rate at 14.8% (332/2,246) over the previous 5 years. Concurrently, the hepatitis B 3-dose vaccine uptake rate was 60.3% (1,316/2,181). Among the participating HCPs, 70.7% (1,457/2,061) had measles immunity due to previous illness (959/2,061, 46.5%), a 2-dose vaccination scheme (461/2,061, 22.4%), or serological confirmation (37/2,061, 1.8%). Vaccine uptake rates differed between groups depending on age, profession, and workplace setting. Logistic regression analysis revealed that risk factors for no influenza vaccine uptake during the previous season were younger age (≤45 years; odds ratio [OR] 1.35, 95% confidence interval [CI]: 1.08-1.66), profession other than physician (OR 2.94, 95%CI: 2.09-4.12), and working in hospitals (OR 1.39, 95%CI 1.02-1.89). Older age (>45 years) was an independent risk factor for not receiving a measles (OR 26.74, 95%CI: 17.41-41.06) or hepatitis B vaccine (OR 1.36, 95%CI 1.09-1.7). Working in primary care was an independent risk factor for not getting a hepatitis B vaccine (OR 1.52, 95%CI: 1.15-2.1). Our findings indicate that individualized and targeted interventions should be implemented to increase vaccine uptake among HCPs.
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Affiliation(s)
- Olga Vrachnaki
- Department of Paediatrics, Heraklion University Hospital , Heraklion, Greece
| | - Eleni Vergadi
- Department of Paediatrics, Heraklion University Hospital , Heraklion, Greece.,Department of Paediatrics, Medical School, University of Crete , Heraklion, Greece
| | - Eleni Ioannidou
- Department of Internal Medicine, Rethymnon General Hospital , Rethymnon, Greece
| | - Emmanouil Galanakis
- Department of Paediatrics, Heraklion University Hospital , Heraklion, Greece.,Department of Paediatrics, Medical School, University of Crete , Heraklion, Greece
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Cheng T, Zhang XL, Hu JJ, Li B, Wang Q. The role of routine screening in blood-borne pathogens in Chinese patients undergoing joint arthroplasty. Bone Joint Res 2017; 6:566-571. [PMID: 28963103 PMCID: PMC5630999 DOI: 10.1302/2046-3758.69.bjr-2017-0066.r2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives Surgeons face a substantial risk of infection because of the occupational exposure to blood-borne pathogens (BBPs) from patients undergoing high-risk orthopaedic procedures. This study aimed to determine the seroprevalence of four BBPs among patients undergoing joint arthroplasty in Shanghai, China. In addition, we evaluated the significance of pre-operative screening by calculating a cost-to-benefit ratio. Methods A retrospective observational study of pre-operative screening for BBPs, including hepatitis B and C viruses (HBV and HCV), human immunodeficiency virus (HIV) and Treponema pallidum (TP), was conducted for sequential patients in the orthopaedic department of a large urban teaching hospital between 01 January 2009 and 30 May 2016. Medical records were analysed to verify the seroprevalence of these BBPs among the patients stratified by age, gender, local origin, type of surgery, history of previous transfusion and marital status. Results Of the subjects who underwent arthroplasty surgery in our institution, pre-operative screening tests were available for 96.1% (11 609 patients). The seroprevalence of HBV, HCV, HIV and TP was 5.47%, 0.45%, 0.08% and 3.6%, respectively. A total of 761 seropositive cases (68.4%) were previously undiagnosed. Pre-operative screening for HIV resulted in a low cost to benefit ratio, followed by HCV and HBV. Conclusion Routine HCV and HIV screening prior to joint arthroplasty is not a cost-effective strategy. Considering the high rate of undiagnosed patients and the shortage of protective options, targeted pre-operative screening for HBV and syphilis should be considered for the protection of healthcare workers in China who have not been vaccinated. Cite this article: Bone Joint Res 2017;6:566–571.
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Affiliation(s)
- T Cheng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - X-L Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - J-J Hu
- Department of Infectious Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - B Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Q Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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Andrew EC, Gibney KB, Denholm J, Leder K. Seroprotection to vaccine-preventable diseases among workers at a Victorian tertiary hospital. Aust N Z J Public Health 2016; 40:284-9. [PMID: 27027875 DOI: 10.1111/1753-6405.12508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/01/2015] [Accepted: 11/01/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine seroprotection for the vaccine-preventable diseases (VPDs) measles, mumps, rubella, varicella and hepatitis B among new employees seen at a Victorian tertiary hospital staff clinic. METHODS Employees who presented to the staff clinic for immunisation assessment between 1 January 2012 and 31 December 2013 were included. Demographic data, self-reported disease history and previous vaccination status were reviewed retrospectively to determine impact on serological results. RESULTS A total of 1,901 new employees were included, 83% of whom were at risk of direct contact with blood or body substances. Overall, the proportion of workers seropositive to measles was 88%, mumps 90%, rubella 78%, varicella 93% and hepatitis B 80%. Staff born before 1966 were more likely to have positive measles or mumps serology but negative rubella or hepatitis B serology (p<0.05 for each). Staff who self-reported measles (99% vs. 93%, p=0.03) or varicella infection (98% vs. 92%, p<0.001) were more likely to be seropositive, but those reporting previous vaccination to measles, mumps or rubella were no more likely to be seropositive. CONCLUSIONS AND IMPLICATIONS This study demonstrated levels of seropositivity of 78-93% for the five VPDs. Despite recognised limitations of serological testing, 10-20% of new employees to a healthcare institution lacking seroprotection represents a potentially unacceptable risk of nosocomial transmission of these VPDs. Our findings support ongoing serological testing of new healthcare staff at risk of direct contact with blood or body substances.
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Affiliation(s)
- Eden C Andrew
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Victoria
| | - Katherine B Gibney
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Victoria.,Department of Epidemiology and Preventive Medicine, Monash University, Victoria
| | - Justin Denholm
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Victoria.,Department of Microbiology and Immunology, University of Melbourne, Victoria
| | - Karin Leder
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Victoria.,Department of Epidemiology and Preventive Medicine, Monash University, Victoria
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Tuckerman J, Thomas N, Marshall HS. Should professionals caring for children be vaccinated? Community perspectives on health care and child care worker immunisation. Vaccine 2016; 34:1726-32. [PMID: 26854908 DOI: 10.1016/j.vaccine.2016.01.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 12/14/2015] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Several immunisations including influenza and pertussis are specifically recommended for healthcare workers (HCW) and childcare workers (CCW). This study aimed to assess community attitudes to HCW and CCW immunisation recommendations for pertussis and seasonal influenza. METHODS A cross-sectional study was conducted by Computer Assisted Telephone Interviewing (CATI) from April to May 2011. Statistical analyses used data weighted to the South Australian population by probability of selection, age, gender and geographical location using benchmarks derived from the 2009 Census population figures. RESULTS Almost all respondents supported vaccination of HCWs and CCWs against pertussis and influenza. For pertussis, 95.3% agreed nurses, 94.9% agreed doctors and 94.7% agreed CCWs have an obligation to be vaccinated. For influenza, 91.4% agreed nurses, 90.7% agreed doctors and 89.9% agreed CCWs have an obligation to be vaccinated. We identified higher support for protection against pertussis compared to influenza for all three groups of workers (p<0.001). There were higher concerns if CCWs compared to HCWs were not vaccinated against pertussis (OR=2.78) and influenza (OR=1.99). Young (18-30 years) and older age (60+ years) and lower educational attainment were predictors of support for HCWs and CCWs to be vaccinated against influenza. For pertussis, lower educational attainment was a predictor of support for HCWs immunisation. CONCLUSIONS Community support for CCW and HCW immunisation is strong with CCW immunisation was considered a priority. Pertussis immunisation was considered a higher priority than influenza immunisation for HCWs and CCWs. CCW immunisation should be considered for inclusion in public health immunisation programmes.
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Affiliation(s)
- Jane Tuckerman
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Women's and Children's Health Network, Adelaide, Australia; School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Natalie Thomas
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Women's and Children's Health Network, Adelaide, Australia
| | - Helen S Marshall
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Women's and Children's Health Network, Adelaide, Australia; School of Medicine, The University of Adelaide, Adelaide, Australia; School of Population Health, The University of Adelaide, Adelaide, Australia; Robinson Research Institute, The University of Adelaide, Adelaide, Australia.
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Black AP, Vilivong K, Nouanthong P, Souvannaso C, Hübschen JM, Muller CP. Serosurveillance of vaccine preventable diseases and hepatitis C in healthcare workers from Lao PDR. PLoS One 2015; 10:e0123647. [PMID: 25874696 PMCID: PMC4397087 DOI: 10.1371/journal.pone.0123647] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/26/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND AIMS Healthcare workers (HCW) have an increased risk of exposure to infectious diseases and are a potential source of infections for their patients. The Lao People's Democratic Republic (Lao PDR) has no national policy regarding HCW vaccinations and routine vaccination coverage is low within the general population. This cross-sectional serostudy determines the level of exposure and risk of infection in Lao HCW against 6 vaccine preventable diseases and hepatitis C. METHODS 1128 HCW were recruited from 3 central, 2 provincial and 8 district hospitals. Sera were tested by ELISA for the presence of antibodies and antigens to hepatitis B, hepatitis C, measles, rubella, varicella zoster, tetanus and diphtheria. RESULTS Only 53.1% of the HCW had protective anti-hepatitis B surface antigen antibodies (anti-HBs) with 48.8% having anti-hepatitis B core antibodies (anti-HBc), indicating previous exposure and 8.0% were hepatitis B surface antigen carriers. 3.9% were hepatitis C seropositive. Measles and rubella antibodies were detected in 95.4% and 86.2% of the HCW, with 11.9% of females being unprotected against rubella. Antibodies against varicella zoster, tetanus and diphtheria were detected in 95%, 78.8% and 55.3%, respectively. Seroprevalence varied according to age, gender and number of children. CONCLUSION An unacceptably high proportion of Lao HCW remain susceptible to infection with hepatitis B, diphtheria, tetanus and rubella. Furthermore, a high number of healthcare workers are chronically infected with hepatitis B and C viruses. These data emphasize the need for a robust HCW vaccination policy in addition to increased awareness within this subpopulation.
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Affiliation(s)
- Antony P. Black
- Institute of Immunology, Luxembourg Institute of Health (former Centre de Recherche Public de la Santé)/Laboratoire National de Santé, Luxembourg, Grand-Duchy of Luxembourg
- Lao-Lux Laboratory, Institut Pasteur du Laos, Vientiane, Lao PDR
| | | | | | | | - Judith M. Hübschen
- Institute of Immunology, Luxembourg Institute of Health (former Centre de Recherche Public de la Santé)/Laboratoire National de Santé, Luxembourg, Grand-Duchy of Luxembourg
- Lao-Lux Laboratory, Institut Pasteur du Laos, Vientiane, Lao PDR
| | - Claude P. Muller
- Institute of Immunology, Luxembourg Institute of Health (former Centre de Recherche Public de la Santé)/Laboratoire National de Santé, Luxembourg, Grand-Duchy of Luxembourg
- Lao-Lux Laboratory, Institut Pasteur du Laos, Vientiane, Lao PDR
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Tuckerman JL, Collins JE, Marshall HS. Factors affecting uptake of recommended immunizations among health care workers in South Australia. Hum Vaccin Immunother 2015; 11:704-12. [PMID: 25715003 PMCID: PMC4514246 DOI: 10.1080/21645515.2015.1008886] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/02/2014] [Accepted: 12/16/2014] [Indexed: 10/23/2022] Open
Abstract
Despite the benefits of vaccination for health care workers (HCWs), uptake of recommended vaccinations is low, particularly for seasonal influenza and pertussis. In addition, there is variation in uptake within hospitals. While all vaccinations recommended for HCWs are important, vaccination against influenza and pertussis are particularly imperative, given HCWs are at risk of occupationally acquired influenza and pertussis, and may be asymptomatic, acting as a reservoir to vulnerable patients in their care. This study aimed to determine predictors of uptake of these vaccinations and explore the reasons for variation in uptake by HCWs working in different hospital wards. HCWs from wards with high and low influenza vaccine uptake in a tertiary pediatric and obstetric hospital completed a questionnaire to assess knowledge of HCW recommended immunizations. Multiple logistic regression was used to determine predictors of influenza and pertussis vaccination uptake. Of 92 HCWs who responded, 9.8% were able to identify correctly the vaccines recommended for HCWs. Overall 80% of respondents reported they had previously received influenza vaccine and 50.5% had received pertussis vaccine. Independent predictors of pertussis vaccination included length of time employed in health sector (P < 0.001), previously receiving hepatitis B/MMR (measles, mumps, rubella) vaccine (P < 0.001), and a respondent being aware influenza infections could be severe in infants (p = 0.023). Independent predictors of seasonal influenza vaccination included younger age (P < 0.001), English as first language (P < 0.001), considering it important to be vaccinated to protect themselves (P < 0.001), protect patients (p = 0.012) or awareness influenza could be serious in immunocompromised patients (p = 0.030). Independent predictors for receiving both influenza and pertussis vaccinations included younger age (P < 0.001), time in area of work (P = 0.020), previously receiving hepatitis B vaccine (P = 0.006) and awareness influenza could be severe in infants (P < 0.001). A knowledge gap exists around HCW awareness of vaccination recommendations. Assessment of the risk/benefit value for HCWs and their patients, determines uptake of HCW immunization programs and should be considered in promotional HCW vaccination programs.
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Affiliation(s)
- Jane L Tuckerman
- Vaccinology and Immunology Research Trials Unit; Women's and Children's Hospital; North Adelaide, South Australia, Australia
- School of Pediatrics and Reproductive Health; University of Adelaide; Adelaide, South Australia, Australia
| | - Joanne E Collins
- Vaccinology and Immunology Research Trials Unit; Women's and Children's Hospital; North Adelaide, South Australia, Australia
- School of Pediatrics and Reproductive Health; University of Adelaide; Adelaide, South Australia, Australia
| | - Helen S Marshall
- Vaccinology and Immunology Research Trials Unit; Women's and Children's Hospital; North Adelaide, South Australia, Australia
- School of Pediatrics and Reproductive Health; University of Adelaide; Adelaide, South Australia, Australia
- School of Population Health; University of Adelaide; Adelaide, South Australia, Australia
- Robinson Research Institute; University of Adelaide; Adelaide, South Australia, Australia
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