Meningococcal, influenza virus, and hepatitis B virus vaccination coverage level among health care workers in Hajj

Background The objective of this study was to assess the compliance of health care workers (HCWs) employed in Hajj in receiving the meningococcal, influenza, and hepatitis B vaccines. Methods A cross-sectional survey of doctors and nurses working in all Mena and Arafat hospitals and primary health care centers who attended Hajj-medicine training programs immediately before the beginning of Hajj of the lunar Islamic year 1423 (2003) using self-administered structured questionnaire which included demographic data and data on vaccination history. Results A total of 392 HCWs were studied including 215 (54.8%) nurses and 177 (45.2%) doctors. One hundred and sixty four (41.8%) HCWs were from Makkah and the rest were recruited from other regions in Saudi Arabia. Three hundred and twenty three (82.4%) HCWs received the quadrivalent (ACYW135) meningococcal meningitis vaccine with 271 (83.9%) HCWs receiving it at least 2 weeks before coming to Hajj, whereas the remaining 52 (16.1%) HCWs received it within < 2 weeks. Only 23 (5.9%) HCWs received the current year's influenza virus vaccine. Two hundred and sixty (66.3%) of HCWs received the three-dose hepatitis B vaccine series, 19.3% received one or two doses, and 14.3% did not receive any dose. There was no statistically significant difference in compliance with the three vaccines between doctors and nurses. Conclusion The meningococcal and hepatitis B vaccination coverage level among HCWs in Hajj was suboptimal and the influenza vaccination level was notably low. Strategies to improve vaccination coverage among HCWs should be adopted by all health care facilities in Saudi Arabia.


Background
Ensuring that health care workers (HCWs) are immune to vaccine-preventable diseases is an essential part of successful employee health programs. Optimal use of vaccines can prevent transmission of vaccine-preventable diseases and eliminate unnecessary work restriction. Prevention of illness through comprehensive HCWs immunization programs is far more cost-effective than case management and outbreak control [1]. In Saudi Arabia, the national vaccination recommendations for HCWs are generally the same as those recommended by the Centers for Disease Control and Prevention [2]. Meningococcal vaccination of all HCWs is additionally recommended in Saudi Arabia, particularly for those working directly with pilgrims in Hajj. Influenza and hepatitis B vaccines are also emphasized for this group of HCWs. These three and other required vaccines are made available free of charge for all HCWs in all health care facilities in Saudi Arabia. The objective of this study was to assess the compliance of HCWs employed in Hajj in receiving the meningococcal, influenza, and hepatitis B vaccines that are particularly recommended for Hajj by the Ministry of Health.

Hajj
Hajj is the fifth of the five pillars of Islam. Any healthy Muslim adult is required to perform Hajj once in his/her life if he/she is financially and physically capable. The Hajj begins on the 8 th day of Dhul-Hijjah, the 12 th month of the lunar Islamic year, and ends on the 13 th day of the same month. Hajj has to be performed in three main locations in Makkah, namely, the sacred Kaaba (in the holy city of Makkah), and Mena and Arafat, which are approximately 5 and 18 Kilometers far from Makkah, respectively. Approximately, 2-3 million pilgrims perform Hajj every year; one third of whom come from within Saudi Arabia and two thirds come from other countries. Most pilgrims stay in fire-resistant air-conditioned camping tents in Mena during the entire Hajj period. Financially deprived pilgrims who cannot afford to pay for the cost of staying in camps usually stay outdoor. Free medical care services are provided to pilgrims by the Saudi Ministry of Health.

Study design and population
A cross-sectional survey was conducted in Mena and Arafat during the Hajj season of the Islamic year 1423 corresponding to 2003 Gregorian. HCWs included in the study were all doctors and nurses working in Mena and Arafat hospitals and primary health care centers who attended Hajj-medicine training programs immediately before the beginning of Hajj. Many of the HCWs were recruited from various regions in Saudi Arabia to supplement the local HCWs working in Makkah to cover the extensive medical services provided to pilgrims in Hajj.

Data collection
The Saudi Ministry of Health approved the study. Data were collected using a structured questionnaire which included demographic data and data on vaccination history. The questionnaire was anonymously self-administered by HCWs with supervision from the research team members.

Data analysis
Data entry and statistical analysis were performed using computer and the Statistical Package for Social Science (SPSS) program. Descriptive statistics, cross tabulations, and Chi-square test were performed as appropriate. Multiple logistic regression analysis was performed to identify predictors of compliance to vaccination after controlling for possible confounding factors. Statistical significance was set at < 0.05.
Only 23 (5.9%) HCWs received the current year's influenza virus vaccine. There was no statistically significant difference in compliance with this vaccine between doctors and nurses (5.6 % versus 7.4 %, respectively, p = 0.573).
Of the 392 HCWs, 260 (66.3%) HCWs completed the three-dose series of the hepatitis B vaccine, 48 (12.2%) HCWs received 2 doses, 28 (7.1%) HCWs received one dose, and 56 (14.3 %) HCWs did not receive any dose of the vaccine. There was no statistically significant difference in compliance with hepatitis B vaccination between doctors and nurses ( Table 2). Of the 260 HCWs who completed the hepatitis B vaccination series, 134 (51.5%) HCWs had post-vaccination tests to confirm development of immunity. Table 3 shows a bivariate analysis of the compliance of 392 health care workers for receiving the quadrivalent meningococcal meningitis, influenza, and hepatitis B vaccines according to their gender, age group, nationality, years of experience, degree, position, and original place of work. This analysis showed no statistically significant difference in compliance with the receipt of the vaccines among the various groups with two exceptions; the compliance of non-Saudi HCWs for the receipt of the meningitis vaccine was significantly higher than that of the Saudi mates (84.2% versus 77.8%, p = 0.027), and the compliance of HCWs with lower degrees (diploma and bachelor) was significantly higher than that of HCWs with higher degrees (p = 0.011). Multivariate logistic regression analysis confirmed that non-Saudi nationality was an independent predictor of a better compliance with the meningitis vaccine (odds ratio = 3.28, 95% confidence interval = 1.17 -9.21, p = 0.024). However, lower degrees were not independent predictors of a better compliance with this vaccine (p = 0.797).

Discussion
Until   During community influenza outbreaks, admitting patients infected with influenza to hospitals has led to nosocomial transmission of the disease, including transmission from staff to patients [4][5][6]. Transmission of influenza among medical staff causes absenteeism and considerable disruption of health care [7][8][9][10]. The Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) in the United States recommend that all HCWs be vaccinated annually against influenza [11]. However, in spite of a long-standing recommendation for influenza vaccination of HCWs, and the availability of a safe and effective vaccine, influenza vaccination coverage levels among HCWs remain substantially low worldwide [11]. For instance, during 1989-2003, HCWs influenza vaccination coverage levels in the United States increased from 10% to 40%; however, coverage levels have remained relatively constant since 1997 [12]. Substantially lower vaccination rates have been reported among HCWs who have contact with certain populations at high risk in the United States [13][14][15][16]. Low influenza vaccination coverage rates have also been reported from Europe [17][18][19][20]. This vaccine is particularly recommended for HCWs working in Hajj because of the very high risk of acquiring influenza infection in such overcrowded situations. However, in this study, only 5.9% of HCWs received the current year's influenza virus vaccine. Gender, age, nationality, years of experience, qualification degree, position, and original place of work were not significant predictors of compliance to this vaccine. Reported barriers to HCWs receipt or acceptance of influenza vaccination include fear of vaccine side effects, insufficient time or inconvenience, perceived ineffectiveness of the vaccine, medical contraindication, perceived low likelihood of contracting influenza, reliance on treatment with homeopathic medications, avoidance of medications, and fear of needles [11].
Hepatitis B virus (HBV) infection is a major infectious hazard for HCWs [11,12]. In general, the seroprevalence of HBV among HCWs is twofold to fourfold higher than that of blood donor controls [23]. The risk for acquiring HBV infection from occupational exposures is dependent on the frequency of percutaneous and permucosal exposures to blood or body fluids containing blood [22]. The risk for transmission from a single needlestick varies according to hepatitis B e antigen status: 1% to 6% for e antigen-negative blood compared with 22% to 40% with e antigen-positive blood [23]. Not all cases of HBV transmission are explained by needlesticks, suggesting that other modes of spread may be possible [23]. HBV vaccination of all HCWs has been strongly recommended [2]. The HBV three-dose vaccine series is 88% effective [24,25]. From 1985 to 1994, the use of HBV vaccine and adherence to other preventive measures such as standard pre-cautions lead to a 90% decline of HBV infection among HCWs in the United States [26,27]. Even though, HBV vaccination of all HCWs has been strongly recommended, the vaccination coverage level of HCWs remains suboptimal with many studies reporting rates between 40-86% [28][29][30][31][32][33][34][35]. A recent study from Saudi Arabia reported an overall compliance rate of 71.6% (932/1302) among HCWs [36]. In that study the compliance rate was 79.5% (492/619) among nurses, 78.3% (242/309) among technicians, and 52.9% (198/374) among physicians [36]. In the current study, the compliance rate was similar to earlier reports as only 66.3% of HCWs received the threedose vaccine series, 19.3% received one or two doses, and 14.3% did not receive any dose. Gender, age, nationality, years of experience, qualification degree, position, and original place of work were not significant predictors of compliance to this vaccine.
Several strategies for improving HCWs vaccination coverage have been recommended [11]. Successful HCWs vaccination programs are multifaceted and combine publicity and education to combat fears and misconceptions about vaccines, use of reminder recall systems, efforts to remove administrative and financial barriers, role modeling, and monitoring and feedback on vaccination coverage [11]. Educational programs should emphasize the benefits of HCWs vaccination for staff and patients [11]. Organized campaigns that promote and make vaccine accessible can improve vaccination rates among HCWs [11]. Vaccination of senior medical staff or opinion leaders has been associated with higher vaccination acceptance among staff members under their leadership [11]. Removing administrative barriers such as costs and providing vaccine in locations and at times easily accessible by HCWs can substantially improve vaccine acceptance [11]. Making vaccine readily accessible at congregate areas (e.g., clinics), during conferences, or by use of mobile carts has been demonstrated to improve vaccination coverage rates [11]. Monitoring vaccination coverage by facility area (e.g., ward or unit) or occupational group allows facilities to identify where vaccination levels are low and interventions that should be targeted. Obtaining declination statements from HCWs who refuse vaccination for reasons other than medical contraindications can assist facilities in identifying personnel who might require targeted education or other interventions to overcome barriers to vaccine acceptance. In addition, collection of such information will allow health-care facilities to determine what proportion of their staff are reached and offered vaccine [11].

Conclusion
The meningococcal and hepatitis B vaccination coverage level among HCWs in Hajj was suboptimal and the influenza vaccination rate was notably low. Recommended strategies to improve vaccination coverage among HCWs should be adopted by all health care facilities in Saudi Arabia to ensure adequate vaccination coverage particularly with the Hajj-related vaccines.