health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

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Page 1: Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

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Vaccine 32 (2014) 5957–5961

Contents lists available at ScienceDirect

Vaccine

j our na l ho me page: www.elsev ier .com/ locate /vacc ine

ealth care professionals’ awareness of, knowledge about andttitude to influenza vaccination

hamir M. Alshammaria,b,∗, Lama S. AlFehaidc, Joud K. AlFraihd, Hisham S. Aljadheyb,e

College of Pharmacy, Hail University, Hail, Saudi ArabiaMedication Safety Research Chair, King Saud University, Riyadh, Saudi ArabiaCollege of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaPrince Mohammad bin Abdulaziz Hospital, Saudi ArabiaCollege of Pharmacy, King Saud University, Riyadh, Saudi Arabia

r t i c l e i n f o

rticle history:eceived 25 February 2014eceived in revised form 30 July 2014ccepted 27 August 2014vailable online 11 September 2014

eywords:nfluenza vaccinettitude and knowledgeealthcare professionalaudi Arabia

a b s t r a c t

Objectives: Influenza vaccination is recommended to all health care professionals (HCPs). However, vac-cination rate among HCPs is low and may be due to uncertainty about the effectiveness of the vaccineand fear of its adverse effects. Therefore, this study aimed to investigate the awareness, knowledge, andattitude of HCPs towards influenza vaccination and we ascertain reasons for not getting vaccinated.Method: A cross-sectional conducted in 6 major hospitals in Saudi Arabia. 245 anonymous questionnaireswere distributed to a convenient sample of staff during the 2012–2013 influenza season. The validatedquestionnaire consists of five sections that collect information about: demographics, attitude towardsinfluenza vaccination, knowledge about influenza virus and vaccination, current practice and awarenessof published guidelines.Results: 242 completed questionnaires were received, a response rate of 98%. 38% of HCPs reported gettingvaccinated. The most common reasons given by HCPs for not getting vaccinated were: fear of contractingillness (16%), belief that they are not at risk from influenza because they are young and healthy (13%)and being unaware of vaccine availability (13%). Non-availability of vaccine (43%) was the highest barrierfor not providing vaccine for patients and HCPs followed by safety concerns for the patients (35%) and

the respondents (33%). Almost 75% of HCPs were not aware of the influenza immunization guidelinespublished by the Advisory Committee on Immunization Practices and Centre for Disease Control.Conclusion: Despite the recommendations, only low percentage of HCPs in Saudi Arabian hospitals isvaccinated against influenza. The attention of health policy makers is needed to improve compliance ofHCPs with guidelines on influenza vaccination.

© 2014 Elsevier Ltd. All rights reserved.

. Introduction

The United States Advisory Committee on Immunization Prac-ices (ACIP) advises all HCPs to be vaccinated against influenza [1].his recommendation and an increased risk of disease among HCPsompared with the general population notwithstanding, world-

ide HCP compliance with influenza vaccination programmes is

nown to be low and is far below the level needed to achieveerd immunity [2,3]. The low vaccination rate in HCPs may be due

∗ Corresponding author at: Department of Clinical Pharmacy, College of Pharmacy,ail University, P.O. Box 6166, Horan Street, Hail 81442, Saudi Arabia.el.: +966 505192886.

E-mail addresses: [email protected], [email protected]. Alshammari).

ttp://dx.doi.org/10.1016/j.vaccine.2014.08.061264-410X/© 2014 Elsevier Ltd. All rights reserved.

to uncertainty about the effectiveness of the vaccine and fear ofits adverse effects [4,5]. However, understanding these barriersis essential to overcoming low compliance with recommenda-tions for vaccination. In our region, few studies have addressedthese issues. In 2010, a study has been conducted in one hos-pital in Saudi Arabia found that there is a poor knowledge ofHCPs towards influenza disease and its prevention and there is amisconception towards influenza vaccine among the respondents[5]. Another study has been conducted in the same year in threemiddle east countries and found there is a lower rate of vacci-nation among these countries [6]. In Saudi Arabia, there are nospecific guideline for HCPs in all health care systems regarding

influenza vaccination. However, the ministry of health advises allvisitors to perform Hajj and/or Umrah to be vaccinated against sea-sonal influenza vaccine. Moreover, HCPs who are working duringHajj season are also recommended to get the seasonal influenza
Page 2: Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

5 Vaccine 32 (2014) 5957–5961

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Table 1Demographic characteristics of participating healthcare professionals (HCPs).

Characteristic Number Percentage

GenderMale 118 48.16Female 127 51.84

Professional titlePhysician 76 31.02Pharmacist 75 30.61Nurse 80 32.65Laboratory specialist 1 0.41Clinical pharmacist 6 2.45Pharmacy resident 1 0.41Physiotherapist 6 2.45

InstitutionGovernmental hospital 171 69.80Private hospital 72 29.39Botha 2 0.82

Vaccinated against influenzaYes 95 38.78

958 T.M. Alshammari et al. /

accine [7,8]. This study explored opinions about, knowledge of,nd attitudes to seasonal influenza vaccination in HCPs; investi-ated the percentage of voluntary immunization against influenzaaccine among HCPs in Saudi Arabia and explored why HCPs did notet vaccinated. Strategies to improve influenza vaccination rates inCPs in Saudi Arabia to make sure those HCPs and their patientsre protected from influenza are proposed.

. Method

This study was a cross-sectional study conducted in 6 majorovernmental and private hospitals in Saudi Arabia. These hospi-als included educational and military hospitals. An anonymous,elf-administered questionnaire was distributed to HCPs during the012–2013 influenza season (between March and May 2013); com-letion of the questionnaire was voluntary. The study was approvedy Medication Safety Research Chair, King Saud University.

.1. Questionnaire items

The questionnaire was composed of five sections. The first sec-ion concerned general information about the participant such asender, professional title and specialty. The second section con-ained questions that measured attitude to influenza vaccinationy asking whether participants routinely got vaccinated against

nfluenza, and their reasons for not getting vaccinated. The thirdection assessed knowledge about influenza virus transmission,ecommended frequency of vaccination and the perceived effec-iveness and risks of the vaccine. The fourth section asked abouturrent practice, including whether their workplace offered thenfluenza vaccine and whether they were interested in partici-ating training related to the influenza vaccine. The final sectionested awareness of published guidelines, susceptibility to and risksssociated with influenza infections for HCPs, signs and symptomsf influenza infection, potential seriousness of influenza, avail-bility of influenza vaccine in different dosage forms and vaccineroperties. The questionnaire was validated and piloted on fif-een HCPs with research experience. Two trained pharmacists wereesponsible for distributing the questionnaires during visits to thearticipating hospitals. In some hospitals, the pharmacist inter-iewed participating HCPs and to obtain answers to the surveyuestions due to difficulties in these hospitals’ HCPs response; inther hospitals, the questionnaires were sent to the HCPs and com-leted questionnaires were collected during a revisit five days later.fter 3 days a second collection visit was made. The questionnaireas voluntary and accepting in the participation in the study and a

eturned and complete questionnaire was taken as consent to par-icipate. HCPs who had not completed the questionnaire within thiseriod were considered non-respondents.

.2. Statistical analysis

Descriptive statistics were produced for all survey items. Dataere analyzed using SAS version 9.2, the chi-squared test was used

or comparisons between categorical variables, and bivariate anal-sis was used to examine associations between vaccination statusnd other independent variables.

. Results

A total of 245 questionnaires were randomly distributed in 6

ajor hospitals in Saudi Arabia with response rate of (98%, n = 242).

omparable numbers of HCPs from the different professions partic-pated (physicians: 31%, pharmacists: 32.41%, nurses: 32%). A ratherigh proportion of HCPs (61.22%) had not received the influenza

No 150 61.22

a Working in government and private hospitals.

vaccine (Table 1); there are a number of different possible rea-sons for non-compliance with vaccination among HCPs. Thirty-ninerespondents (16%) stated that the vaccine would have a negativeinfluence on their health and make them ill, thirty-two respon-dents (13%) believed they were not at risk of getting influenza asthey were young and healthy. Nineteen respondents (8%) believedthat they protected themselves from getting influenza by followingall the required precautions e.g. washing hands and covering theirnose and mouth when sneezing or coughing (Fig. 1). There wasno significant difference in the rate of vaccination in pharmacistsand other HCPs (p = 0.14), whilst the rate of vaccination in physi-cians was lower than for other HCPs (p = 0.03); nurses were the HCPgroup mostly likely to get vaccinated and had a higher rate of vac-cination (p = 0.001). Caution is needed in interpreting these resultsas the total number of vaccinated HCPs was low.

However, the majority of respondents (71%, n = 174) believedthat the influenza vaccine is effective in preventing influenza. Ofthose, 44% have been vaccinated compared to 66% who did not(p = 0.01). Believe in the effectiveness of the vaccine was loweramongst pharmacists than other HCPs (p = 0.01); nurses were mostlikely to believe the vaccine to be effective, followed by physicians,nurses were more likely than other HCPs to believe the vaccine to beeffective (p = 0.01). More than half the HCPs (65%, n = 158) said thatCentre for Disease Control (CDC) recommended that they receivethe influenza vaccine and the majority of HCPs believed that theinfluenza vaccine should be administered annually (80%, n = 195),(Table 2). Around 70% (n = 171) of HCPs believed that administra-tion of the influenza vaccine should be part of their medical practiceand over 71% (n = 174) of HCPs thought that they were encour-aged to get vaccinated to protect them from catching influenza bydirect exposure to sick patients, 51% (n = 126) believed that beingvaccinated would minimize their sickness absence and loss of pro-ductivity and make them more able to take care of their patients.Eighty percent of participating HCPs had not received any train-ing relating to influenza vaccination in the last 12 months; over69% wanted to take training courses (such as continuing educationon importance of influenza vaccine and the benefit of the vaccina-tion) in vaccination. About 29% of the participants did not knowwhether their institution offered the influenza vaccine, although50% reported that their institution did offer the influenza vaccine.About one third of the participants reported that they do not pro-

vide any information to the patients or public about the importanceof influenza vaccination.

Over one third (38%, n = 93) believed that influenza vaccinationprotects vulnerable patients and enhances patient safety during

Page 3: Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

T.M. Alshammari et al. / Vaccine 32 (2014) 5957–5961 5959

2%

Fea r of contract ing ill ness

Youg & healthy

They don’t know where to get the full shot

They do the right aseptic technique

The flu is not serious

They can't aff ord to get the ful l shot

They do n’t like needles

The vc cine is mor e da nge rous tha n the virus

The vaccine doesn’t work

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Fig. 1. HCPs’ reasons for non-compl

utbreaks of influenza. Barriers that HCPs believe that prevent themnd their institutions from providing the influenza vaccine to somer all their patients and HCPs included, non-availability of vaccine43%) followed by safety concerns for patients (35%) and for HCPs33%). In addition, 19% and 13% of the participants think that bothimited number of staff and lack of trained staff, respectively, wereonsidered as barriers of not providing influenza vaccine. While,4% considered cost of the vaccine is an important barrier (Fig. 2).bout two thirds (65%, n = 159) of the HCPs were aware of influenza

nfection, but almost 75% (n = 184) were not aware of the ACIP orDC guidelines on influenza immunization.

Table 3 shows the awareness of HCPs towards influenza andnfluenza vaccine. About 85% of the respondents believe thatnfluenza is more serious than common cold and 96% of them knowhe significant symptoms of influenza. Moreover, HCPs 76% of theespondents believe that asymptomatic infected HCPs could stillpread the infection to other close people. In addition, 53% of theespondents believe that the influenza vaccine should have theorrect mix of virus strains to work effectively.

. Discussion

Our study investigated knowledge of, and attitude to seasonal

nfluenza vaccination in HCPs. Several studies have shown thatnfluenza vaccination is effective in protecting HCPs against infec-ion, minimizing transmission of the disease to their patients andecreasing mortality and morbidity among vulnerable patients;

0% 5% 10%

Vac cine is not available

Safety co ncern for patients

Safety concern for HCPs

Not enough s taff to admini ster vaccine

Cost/reimbursement issues of vaccine

Tra ining an d r eadiness of staff

Need for proper storage of vaccine

Need for ancill ary supplies

Fig. 2. Barriers to provision of the influ

4% 6% 8% 10% 12% 14% 16% 18%

with vaccination recommendations.

vaccination also reduced absenteeism and improved the health sta-tus of HCPs [9–12]. The results of the present study revealed a lowpercentage of influenza immunization among HCPs (38%) duringthe 2012–2013 season despite the ACIP and CDC recommendationsand HCPs being at high risk of infection. This rate is similar to thatreported in other studies of influenza vaccination in HCPs in SaudiArabia [5,13]. A cross-sectional study conducted by Rehmania andMemonet with 512 participants found influenza vaccination rateof 34% in the 2008–2009 season [5]. Rates in neighbouring coun-tries have been very variable; a very low influenza vaccination ratewas reported from United Arab Emirates (24.7%), but high rateswere found in Kuwait (67.2%) and Oman (46.4%) [6]. However, wefound no difference between the vaccination rate for pharmacistsand other HCPs (p = 0.14), but physicians were less likely to get vac-cinated than other HCPs (p = 0.03) and nurses more likely to getvaccinated than other HCPs (p = 0.001). Because the overall rateof vaccination of HCPs was low in our study the results shouldbe interpreted with caution. Similarly to other reports [4–6], ourdata revealed significant gaps in HCPs’ knowledge about influenzavaccination. The low rate of immunization in HCPs practising inSaudi Arabia seems likely to be related to lack of knowledge andawareness; however this study did not demonstrate a consistentpositive correlation between HPCs’ belief in the effectiveness of the

influenza vaccine and the decision to be immunized. The resultsof our study showed that 71.43% of participants believed thatinfluenza vaccine is effective in preventing influenza; nonethe-less the self-reported vaccination rate was low. In addition, our

15% 20% 25% 30% 35% 40% 45% 50%

enza vaccine in HCP institutions.

Page 4: Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

5960 T.M. Alshammari et al. / Vaccin

Table 2Knowledge of health care professionals (HCPs) about the influenza vaccine.

Questions Frequency No. (%)

Do you think the influenzavaccine is effective inpreventing the ‘flu?a

Yes 175 71.43No 67 27.35

Do you believe that the Centrefor Disease Control (CDC)recommends that health careworkers receive the’ flu shot?b

Yes 158 64.49No 25 10.20I don’t know 61 24.90

How often do you think the’ fluvaccine should beadministered?c

Every 6 months 27 11.02Every year 196 80Every 5 years 12 4.9Once in a lifetime 10 4.08

Are you aware of the guidelinespublished by the AdvisoryCommittee on ImmunizationPractices (ACIP) or Centre forDisease Control (CDC) forinfluenza immunization?

Yes 56 22.86No 183 74.69

a 3 respondents (1.22%) did not answer this question.b 1 respondents (0.41%) did not answer this question.c 5 respondents (2.04%) did not answer this question.

Table 3Awareness of healthcare professionals (HCPs) about influenza and the influenza vaccine.

Questions Correct

Health care professionals are less susceptible to influenza infections than other peoplea

Number 39

Percentage 15.92

Influenza is transmitted primarily by coughing and sneezinga

Number 222

Percentage 90.61

Influenza is more serious than a “common cold”a

Number 210

Percentage 85.71

The signs and symptoms of influenza include fever, headache, sore throat, cough, nasalNumber 234

Percentage 95.51

HCPs can spread influenza even when they are feeling wella

Number 185

Percentage 75.51

People with influenza can transmit the infection only after their symptoms appeara

Number 60

Percentage 24.49

Influenza is transmitted primarily by contact with blood and body fluidsa

Number 48

Percentage 19.75

Influenza vaccination may not work if the vaccine contains the wrong mix of virusesa

Number 131

Percentage 53.47

The flu shot contains live viruses that may cause some people to get influenzaa

Number 118

Percentage 48.16

Influenza vaccination does not work in some persons, even if the vaccine has the right mNumber 122

Percentage 49.80

Adults with influenza commonly experience nausea and vomiting or diarrheaa

Number 88

Percentage 35.92

Symptoms typically appear 8–10 days after a person is exposed to influenzaa

Number 96

Percentage 39.18

a 2 respondents (0.82%) did not answer this questions.

e 32 (2014) 5957–5961

data showed variable levels of awareness of and knowledge aboutinfluenza vaccination in HCPs (see Tables 2 and 3 for details),broadly in line with other studies [5,14,15]. Most HCPs had basicknowledge of the influenza vaccine and infection and most partici-pating HCPs were aware that people with asymptomatic influenzacan transmit influenza (75.5%); a find which contrasts with Khaz-aeipour et al.’s [16] study in which only 32.4% of HCPs statedthat people with asymptomatic influenza can transmit influenza.Previous studies have reported variable rates of belief amongsthealthcare workers (HCWs) that the influenza vaccine can causeinfluenza infection (38.1% to 78%) [14,15]; 48.16% of all respondentsin our study shared this misconception. 80% of the participantswere aware of the programme of influenza vaccination for HCPsyet 61% % [who may or may not have been aware] declined vacci-nation. Other studies have reported that in Saudi Arabia about 86%of participants were aware of the ACIP recommendation and in thethree Middle East countries – United Arab Emirates, Kuwait andOman – 48.5% of HCWs were aware of the CDC recommendationsfor vaccination against seasonal influenza [5,6]; we found muchlower awareness of these guidelines: about 74.69% of participat-ing HCPs were not aware of the ACIP or CDC recommendations forinfluenza immunization. In this study the most commonly reportedreasons for non-compliance with vaccination recommendationswere fear of contracting illness and concerns about side-effectsof the influenza vaccine such as fever, fatigue and myalgia. Thesefindings are consistent with other studies which investigated par-

ticipants’ main reason for not taking up influenza vaccination. Thissuggests that vaccination campaigns should include facts aboutthe rate of adverse reactions to the influenza vaccine. Other rea-sons given by HCPs for non-compliance included the belief that

Incorrect Not sure

190 1477.55 5.71

13 85.31 3.27

16 176.53 6.94

congestion, and aches and painsa

5 42.04 1.63

31 2712.65 11.02

146 3759.59 15.10

162 3166.67 12.76

34 7813.88 31.84

67 5827.35 23.67

ix of virusesa

35 8614.29 35.10

83 7233.88 29.39

58 8923.67 36.33

Page 5: Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination

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hey were not at risk of getting influenza as they were young andealthy (13%); another study reported a somewhat similar result,ith 6.2% of HCPs citing a belief that they were not at risk of

nfection as their reason for non-compliance with vaccination rec-mmendations [16]. In this study, 43% of participants reported thatvailability of influenza vaccine was a barrier to their institutionffering vaccination; the safety concerns of patients (35%) and HCPs33%) were also cited as barriers to provision of vaccination to bothatients and HCPs. In a study of attitudes and practice relating to

nfluenza vaccination in registered nurses conducted in 4 US statesaccine supply (6%) and safety concerns (39%) were considered bar-iers to the provision of the influenza vaccination [17]. Awarenessf availability of influenza vaccine is sometimes viewed as a bar-ier to influenza vaccination in HCPs, one study found that 98% ofespondents were aware that their institution offered free vacci-ation [4]; but in our study about 29% of the participants did notnow if their institution offered influenza vaccination and only 50%eported that their institution offered influenza vaccine.

A lot of work is needed to increase HCPs’ compliance withnfluenza vaccination recommendations; interventions shouldnclude educational campaigns to address misconceptions. Suc-essful vaccination programmes combine publicity and educationor HCPs and other potential vaccine recipients, use of reminder andecall systems, assessment of organization-level vaccination ratesombined with feedback to staff, and efforts to remove administra-ive and financial barriers to vaccination.

This study has both strengths and limitations. The limitationf this study include that, influenza vaccination status was self-eported by respondents, not subject to independent verificationnd potentially influenced by social desirability bias. In addition,he results of this study cannot be generalized to other HCPs. Also,ur sample size was either similar or smaller than in other studies.owever, our study has several strengths; data was collected from

major hospitals, including government and private hospitals inrder to assess practice in both types of hospital. The response rateor the survey was 98%, higher than that achieved in previouslyublished studies. The majority of respondents were from govern-ent hospitals (69.80%). We also examined the vaccination rate

ccording to professional title; this should enable interventions tomprove compliance with influenza vaccination recommendationso target the group with the lowest rate of vaccination.

. Conclusion

Despite the recommendations, the percentage of HCPs whoeceive the influenza vaccine was low in Saudi Arabian hos-

itals. Concerns about the efficacy and safety of the influenzaaccine, fear of contracting illness, and unavailability of influenzaaccine in some hospitals were significantly associated with non-ompliance with vaccination. More efforts by health authorities and

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regulatory in Saudi Arabia are needed to enhance compliance of allHCPs with recommendations for influenza vaccination; all HCPsshould be encouraged to get vaccinated and make sure it is avail-able in all hospitals, and special educational and campaign shouldbe used to improve their knowledge and awareness.

Conflict of interest

There is no conflict of interest to declare.

References

[1] Pearson ML, Bridges CB, Harper SA. Influenza vaccination of health-care person-nel: recommendations of the Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) and the Advisory Committee on Immunization Practices(ACIP). MMWR Recomm Rep 2006;55:1–16.

[2] Song JY, Park CW, Jeong HW, Cheong HJ, Kim WJ, Kim SR. Effect of a hospitalcampaign for influenza vaccination of healthcare workers. Infect Control HospEpidemiol 2006;27:612–7.

[3] Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenzavaccination among health care workers: a randomized controlled trial. J PublicHealth Med 2001;23:346–8.

[4] Douville LE, Myers A, Jackson MA, Lantos JD. Health care worker knowledge,attitudes, and beliefs regarding mandatory influenza vaccination. Arch PediatrAdolesc Med 2010;164:33–7.

[5] Rehmani R, Memon JI. Knowledge, attitudes and beliefs regarding influenzavaccination among healthcare workers in a Saudi hospital. Vaccine2010;28:4283–7.

[6] Abu-Gharbieh E, Fahmy S, Rasool BA, Khan S. Influenza vaccination: healthcareworkers attitude in three Middle East countries. Int J Mol Sci 2010;7:319–25.

[7] Ministry of Health (Saudi Arabia).Health regulations for the 1435H-Hajj season. 2014. http://www.moh.gov.sa/en/Hajj/News/Pages/News-2014-04-03-001.aspx [accessed on 23.05.14].

[8] World Health Organization (WHO). Weekly epidemiological record, 30. 2012.p. 277–88. http://www.who.int/wer/2012/wer8730.pdf?ua=1 [accessed on23.05.14].

[9] Benet T, Regis C, Voirin N, Robert O, Lina B, Cronenberger S, et al. Influenza vac-cination of healthcare workers in acute-care hospitals: a case–control studyof its effect on hospital-acquired influenza among patients. BMC Infect Dis2012;12:30.

10] Saxen H, Virtanen M. Randomized, placebo-controlled double blind study onthe efficacy of influenza immunization on absenteeism of health care workers.Pediatr Infect Dis J 1999;18:779–83.

11] Carman WF, Elder AG, Wallace LA, McAulay K, Walker A, Murray GD, et al.Effects of influenza vaccination of health-care workers on mortality of elderlypeople in long-term care: a randomised controlled trial. Lancet 2000;355:93–7.

12] Benowitz I, Esposito DB, Gracey KD, Shapiro ED, Vazquez M. Influenza vaccinegiven to pregnant women reduces hospitalization due to influenza in theirinfants. Clin Infect Dis 2010;51:1355–61.

13] Al-Tawfiq JA, Antony A, Abed MS. Attitudes towards influenza vaccina-tion of multi-nationality health-care workers in Saudi Arabia. Vaccine2009;27:5538–41.

14] Wicker S, Rabenau HF. Vaccination rates of healthcare workers vary accordingto their occupational group. Procedia Vaccinol 2011;4:14–8.

15] Nichol KL, Lind A, Margolis KL, Murdoch M, McFadden R, Hauge M, et al. Theeffectiveness of vaccination against influenza in healthy, working adults. N EnglJ Med 1995;333:889–93.

16] Khazaeipour Z, Ranjbarnovin N, Hoseini N. Influenza immunization rates,knowledge, attitudes and practices of health care workers in Iran. J Infect DevCtries 2010;4:636–44.

17] Clark SJ, Cowan AE, Wortley PM. Influenza vaccination attitudes and practicesamong US registered nurses. Am J Infect Control 2009;37:551–6.