Hail Community Acceptance of A/H1N1 Vaccine
The advent of the 2009 influenza A (H1N1) pandemic in April 2009 made the 2009-10 influenza season highly unusual. Public awareness of the potential seriousness of influenza was heightened by media coverage of pandemic-associated hospitalizations and deaths, especially among younger persons. The aim of our study was to investigate the attitude of Hail population towards this vaccine and possible factors associated with vaccine uptake and the effect of Hail University A/H1N1 awareness campaign conducted during the last pandemic of the disease. Design cross sectional study using self administered, anonymous questionnaires Setting Surveys at Hail University from 2nd of Nov. 2009 to 1st of Jan. 2010. A sample of 363 individuals, 277 males and 86 females from University of Hail students and personnel completed the questionnaire in the study. The overall willingness to accept pre-pandemic A/H1N1 vaccine was only (11.49%) to taking the vaccine while more than half the participants (53.44%) refused to take the vaccine. These ratios were statistically significantly different (p<0.001) of vaccination against the 2009 pandemic influenza among Hail population. The major barriers identified were fear of side effects and doubts about its efficacy. The willingness to accept pre-pandemic influenza vaccination was low and no significant effect was observed with the change in WHO alert level. Further studies are required to elucidate the root cause of the low intention to accept pre-pandemic vaccination.
Received: June 29, 2010;
Accepted: September 13, 2010;
Published: November 27, 2010
The advent of the 2009 influenza A (H1N1) pandemic in April 2009 made the 2009-10
influenza seasons highly unusual (Jaafar-Furo et al.,
2008; Sur et al., 2009; Sar
et al., 2010; To et al., 2010). Public
awareness of the potential seriousness of influenza was heightened by media
coverage of pandemic-associated hospitalizations and deaths, especially among
younger persons. The mass influenza immunization program initiated in the United
States in the fall of 1976 was a unique public health measure in terms of the
numbers to be inoculated and the speed with which this was to be accomplished.
By the time immunizations were suspended on December 16, more than 40 million
doses of vaccine containing either A/New Jersey/8/76 (HswlNl) alone, or A/New
Jersey plus A/Victoria/ 3/75 (H3N2) had been given (Poe
and Massey, 1977). As of 31 January 2010, worldwide more than 209 countries
and overseas territories or communities have reported laboratory-confirmed cases
of 2009 pandemic influenza A (H1N1). In addition, at least 15,174 deaths related
to this infection have been recorded (WHO, 2009). In
Europe, the pandemic is well past its peak and medium intensity transmission
is now confined to five countries, all in eastern or south-eastern Europe. One
of those countries is Greece, where the recorded number of fatal cases caused
by 2009 pandemic influenza is currently 118 (ECDC, 2010).
According to recommendations from the World Health Organization (WHO) all countries
should immunize their healthcare workers as a first priority in order to protect
the vital health infrastructure (WHO, 2010). In Saudi
Arabia, a survey carried out among medical consultants covering 60 consultants
and medical professors who were selected randomly from Saudi hospitals and medical
colleges. The survey focused on the opinions of internists, pediatricians and
family doctors. It asked medical experts whether they would take the vaccine,
whether they would allow their children to take the vaccine and whether they
can convince others of their views. Out of 60 doctors, 52 (80%) said they would
not take the vaccine. A similar number of doctors said they would not allow
their children to take the vaccine. Only 13 doctors (20%) said they would agree
to take the vaccine while 11 (17%) said they would allow their children to take
the vaccine. Twenty-five of the 52 doctors who had said they would not take
the vaccine said they would advise other people not to take the vaccine. But
the remaining doctors said they would not advise others. The second survey covered
consultants at clinical pharmacies, dentists and health experts, adding that
all of the participants unanimously said that they would not take the vaccine
and would not give it to their children. According to another survey conducted
at King Saud University College of Medicine, the bulk of 226 final year medical
students opposed taking the vaccine. As many as 198 students (88%) said they
would not approve taking the vaccine while 28 students said they would (Crossroad
Arabia, 2009). To our knowledge, information on healthcare workers
intention to take up vaccination against the 2009 pandemic influenza is sparse
(Chor et al., 2009). Consequently, the aim of
our study was to investigate the attitude of Hail University population workers
towards this vaccine and possible factors associated with vaccine uptake.
MATERIALS AND METHODS
A structured, self-administered, anonymous questionnaire was distributed to a convenience sample of 363 individuals, 277 males and 86 females from University of Hail students and personnel from 2nd of Nov. 2009 to 1st of Jan. 2010. The survey was conducted on 2nd of Nov. 2009, one week before the official start of national vaccination campaign against the 2009 pandemic influenza A(H1N1) in Saudi Arabia. The questionnaire included questions on demographics, willingness to accept seasonal influenza vaccination and willingness to accept the 2009 pandemic influenza vaccine. In the case of vaccination refusal the participants were requested to define the reason: lack of time, inertia; perception of not being at risk of serious illness, use of alternative drugs and fear about vaccine safety. In the case of fear about vaccine safety, the participant was requested to specify the concern given the following alternatives. Moreover, the target group was asked about their level of information on the safety of pandemic influenza A (H1N1) vaccines (no information/insufficient information, sufficient/very good information) and on their sources of information on influenza A (H1N1) vaccine safety: Internet, family doctors, medical journals/books, television and radio stations, newspapers/magazines, representatives of pharmaceutical companies. Finally, participants were asked to express their opinion on the value of vaccinations as an important means for the protection of public health and in particular of their family members.
As shown in Table 1, the study was conducted on 363 individuals, 277 males and 86 females, most of them (80.44%) are from the students of Hail University. Most of them are not married. The largest proportion of the participants was under twenty years (45.73%, p<0.001).
||Characteristics of the participants in the questionnaire
With respect to the level of education, most of the participants were universally educated or postgraduate studies (91.45%, p<0.001). Most of the participants were not working in health field (78.51%, p<0.001).
The first question asked was did you hear about the disease? The result was highly significant (p<0.001) since 97.79% of the participants heard about the swine flu disease. With respect to the symptoms of the disease, 57.30% of the participants answered yes, 9.36% answered No while the rest of them (33.33%) answered little meaning that they have little information about the symptoms of the disease. About the mode of infection, 67.76% said that the infection is transmitted through the air. In the same time, 70.24% said that infection transmits through dealing with the patients whereas 42.69% said that use of the patient tools is the cause of infection. These proportions were statistically significant (p<0.001). With respect to the danger of the disease, 55.37% said that the disease is dangerous, 26.72% said that the disease is very dangerous while 14.87% said that the disease is not dangerous (p<0.001). The treatment of the disease was controversial in such a way that 43.25% said that the antiviral agents are the optimal treatment for the disease while 19.01% said that the treatment is the antibiotics. A small proportion of the participants (15.70%) said that the disease has no treatment (p<0.001). With respect to the precautions must be taken to avoid the disease, 75.77% said that avoiding the patient is the most important precaution while 56.74% said that washing the hand is the precaution of choice, others (55.37%) said that wearing of mask is more important (p<0.001). What population of people may be at risk?. A question answered by the participants as follows: a ratio of 71.91% answered that children are the population of choice while 35.26% said that pregnant are mostly subjected to the disease whereas 11.02% only said that adults are the high risk population. In addition, 44.62% said that elders are more subjected to the disease due to their weak immunity. Finally, a ratio of 13.22% said that they dont know exactly who the persons at high risk for the disease are. About worrying from the disease, about half the participants (50.13%) said that they not worried while those who are worried were 37.46% and very worried were 12.39% of the participants. With respect to the information about the disease, media were the major source of information for most of the participants (88.71%) while the other sources recorded nearly equal ratios; friends (15.15%), university (19.55%), family (15.42%). All these ratios were statistically significant (p<0.001, Table 2).
The first question directed to the participants was Do you know that there
is a vaccine for the swine flu?. Off course, the majority of them (94.49%) answered
yes whereas, a very small proportion (5.51%) answered No (p<0.001, Table
||Questions about the swine flu disease
With respect to the usefulness of the vaccine, 20.11% only said that it is
useful, while 34.74% said that the vaccine is useless whereas 42.42% selected
the choice of I dont know (p<0.001, Table 3). With
respect to the possible danger due to taking the vaccine, 45.45% of the participants
said that the vaccine is dangerous while 12.12% only said that the vaccine may
be not dangerous whereas a ratio of 42.42% said I dont know (p<0.001,
Table 3). About the knowledge of the participants with the
vaccine, 85.39% had their information from media, 19.56% from friends, 22.58%
from family and finally 6.33% from the family physician (p<0.001). The crucial
question was Do you accept to take the vaccine? A very little ratio of the participants
(11.49%) accepted taking the vaccine while more than half the participants (53.44%)
refused taking the vaccine. The rest of the participants (35.26%) said that
they did not decide yet. These ratios were statistically significantly different
(p<0.001, Table 3). The role of media in raising awareness
of the participants about the disease and the vaccine was enough in the opinion
of 53.16% of the participants while 31.40% said that the role of media was not
enough whereas the rest (15.42%) were neutral for this question. These ratios
were varied significantly (p<0.001). With respect to the effect of media
on the decision to take the vaccine, a total of 57.84% said the media were effective
(38.01%) or very effective (19.83%) while 34.16% said that media were not effective
whereas the rest (9.09%) of the participants were neutral for this question
(p<0.001, Table 3). About the impact of the community on
the decision to take the vaccine, 59.23% said the community was effective (34.16%)
or very effective (25.07%).
||Questions about the vaccine of swine flu disease
A ratio of 34.16% said that the community was not effective while the rest
(10.19%) was neutral (p<0.001, Table 3). With respect to
the presence of a political or economic dimension about taking the vaccine,
37.74% answered Yes, 15.70% answered No while nearly half the participants (46.55%)
said I dont know. these ratios were significantly different (p<0.001,
Table 3). Consent must be taken from the participant before
taking the vaccine. This consent was one of the effective reasons led to the
rejection of the vaccine where 40.49% of the participants said that the consent
was affecting their decision to take the vaccine. On contrary, a ratio of 31.13%
said that the consent was not effective while the rest of the participants were
neutral (28.37%). All these ratios were significantly different (p<0.001,
Table 4 shows the main reasons for rejection of taking the vaccine. These reasons can be summarized in the probable danger and the doubt usefulness and the consent before taking the vaccine. For the danger of the vaccine, 45.45% of the participants said that the vaccine is dangerous and so they refuse to take. With respect to the usefulness of the vaccine, only 20.11% said that it is useful and the vast majority said that it is not useful or with doubtful benefit and so they refuse the vaccine for this reason. The consent taken before vaccination was one of the most reasonable causes of rejection because it confirmed the dangerous effect of taking the vaccine. A ration of 40.49% of the participants confirmed that the consent had a strong impact on their decision to take the vaccine.
||Association between the acceptance or rejection of taking
vaccine and some important other questions
Present study revealed a low acceptance from the participants (11.49%) to taking
the vaccine while more than half the participants (53.44%) refused taking the
vaccine. The rest of the participants (35.26%) said that they did not decide
yet. These ratios were statistically significantly different (p<0.001, Table
3) of vaccination against the 2009 pandemic influenza among Hail population.
There is some evidence that the willingness of Saudi healthcare workers to be
vaccinated with seasonal influenza vaccine is slightly high (20%) 6 comparing
to the European healthcare workers to be vaccinated with seasonal influenza
vaccine which ranging from 14% in the United Kingdom to the very high (48%)
among French (NSIVSE., 2007). In a Canadian qualitative
study among health care professionals and the general public, the authors found
that individuals were hesitant to accept pandemic vaccines and that concerns
about using new vaccines during a pandemic differ from concerns about using
established products in non-crisis situations (Sencer and
Millar, 2009). In France, studies conducted by Schwarzinger
et al. (2010) found that acceptability of A/H1N1 pandemic vaccination
was as low as 17.0% among the French adult population and concerns about A/H1N1
pandemic vaccine safety were the main reason quoted by 71.2% respondents who
denied being vaccinated. To et al. (2010) found
that only 13.3% of the respondents planned to receive the H1N1 vaccine, compared
with 37.5% for the seasonal influenza vaccine. Vaccination against seasonal
influenza in the preceding season strongly predicted the likelihood of H1N1
vaccination. In Addition, Eastwood et al. (2010)
found in Australia that of 1155 possible participants, 830 (72%) were successfully
interviewed. Twenty percent of the study group (169/830) reported that they
had developed influenza-like symptoms during the 2009 pandemic period. Most
respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease
and 211/830 (25%) regarded themselves as being at increased risk of infection.
Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%)
but was significantly lower than when pandemic vaccination uptake was investigated
in 2007 (88%; p<0.0001). Respondents who had already been vaccinated against
seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe
were significantly more willing to accept vaccination. Most respondents (793/822,
96%) were willing to share surplus vaccine with developing countries in our
region. Finally, in Canada, Dubre et al. (2010)
found that 72% and 92% of 921 questionnaires agreed with the statements regarding
vaccine safety, effectiveness and acceptability. More than 75% of respondents
intended to recommend the A (H1N1) pandemic influenza vaccine to their patients
and to get vaccinated themselves.
Present results primarily suggest that the general population was not reassured
that A/H1N1 pandemic vaccines were safe. It calls into question the information
received by the general population at time of the survey and what factors may
have worsened the perception that A/H1N1 pandemic vaccines are unsafe. On the
one hand, the severity of A/H1N1 2009 influenza illness was stressed by daily
reports of fatalities in the news media, frequent messages from public health
authorities and personal appearances in the media of the Ministry of Health
and the awareness campaign conducted by Hail University in order to motivate
peoples compliance with the mass vaccination campaign. On the other hand,
the safety of A/H1N1 pandemic vaccines was scrutinized by the media and public
websites discussion boards with regard to the risk of Guillain-Barre` syndrome,
the limited knowledge about the vaccines accounting for almost all doses available
in Saudi Arabia, the accelerated authorization procedure to market pandemic
vaccines and the actual motivations of pharmaceutical firms, while the unclear
number of vaccine injections called their protective efficacy into question.
The low acceptance rate of the pandemic vaccine among Hail population is alarming
given that they are not clearly educated by their health providers because the
researches revealed that health workers have being used as an example for their
patients and the public (ECDC, 2009). Vaccination is
important in order to keep the healthcare system operating at maximum capacity
during a pandemic (Jordan and Hayward, 2009). Policy
makers in Saudi Arabia and maybe in other countries in EMRO could consider our
findings in order to improve the vaccination strategy for healthcare workers
in future vaccination campaigns. In addition, our study shows that the implementation
of a mass vaccination campaign and the particular role given to primary care
physicians were major factors to achieve a successful pandemic vaccination campaign.
We would like to thank Dr. Othman Al-Amoody, Dr. Nabeel Shalabi, all University of Hail Staff and our students for their help with this study.
Chor, J.S.Y., K.K.L. Ngai, W.B. Goggins, M.C.S. Wong and S.Y.S. Wong et al
Willingness of Hong Kong healthcare workers to accept prepandemic influenza vaccination at different WHO alert levels: Two questionnaire surveys. BMJ., 339: 3391-3391.CrossRef |
Crossroad Arabia, 2009.
Saudi doctors and swine flu vaccine. http://xrdarabia.org/2009/10/24/saudi-doctors-swine-flu-vaccine/.
Dubre, E., V. Gilca, C. Sauvageau, N. Boulianne and F.D. Boucher et al
Canadian family physicians and paediatricians knowledge attitudes and practices regarding A(H1N1) pandemic vaccine. BMC Res. Notes, 3: 102-102.Direct Link |
Pandemic influenza A (H1N1). Executive update. 2009.
Ja'afar-Furo, M.R., H.G. Balla, A.S. Tahir and C. Haskainu, 2008.
Incidence of avian influenza in Adamawa state, Nigeria: The epidemiology, economic losses and the possible role of wild birds in the transmission of the disease. J. Applied Sci., 8: 205-217.CrossRef | Direct Link |
Jordan, R. and A. Hayward, 2009.
Should healthcare workers have the swine flu vaccine. BMJ., 339: 3391-3391.CrossRef |
To, K.W., S. Lee, T.O. Shan and S.S. Lee, 2010.
Exploring determinants of acceptance of the pandemic influenza A (H1N1) 2009 vaccination in nurses. Am. J. Infection Control,CrossRef |
Eastwood, K., D.N. Durrheim, A. Jones and M. Butler, 2010.
Acceptance of pandemic (H1N1) 2009 influenza vaccination by the Australian public. Med. J. Australia, 192: 33-36.Direct Link |
Final report venice group, 2008. Collaboration between VENICE project and ECDC.
Poe, G.S. and J.T. Massey, 1977.
Estimating influenza cases and vaccinations by means of weekly rapid reporting system. Public Health Rep., 92: 299-306.Direct Link |
Sar, T.T., P.T. Aernan and R.S. Houmsou, 2010.
H1N1 influenza epidemic: Public health implications for Nigeria. Int. J. Virol., 6: 1-6.CrossRef | Direct Link |
Schwarzinger, M., R. Flicoteaux, S. Cortarenoda, Y. Obadia and J.P. Moatti, 2010.
Low acceptability of A/H1N1 pandemic vaccination in french adult population: Did public health policy fuel public dissonance. PloS One, 5: 10199-10199.CrossRef |
Sencer, D.J. and J.D. Millar, 2009.
Reflections on the 1976 swine flu vaccination program. Emerg. Infect. Dis., 12: 29-33.
WHO recommendations on pandemic (H1N1) 2009 vaccines. Pandemic (H1N1) 2009 Briefing Note 2.
Pandemic (H1N1) 2009-update 86. Weekly Update, http://www.who.int/csr/don/2010_02_5/en/index.html.
Why health care workers are apriority group for pandemic influenza A (H1N1) vaccination?. Annual Report of the Director 2009 (May 2010).
Sur, S., G. Sen, S. Thakur, A.K. Bothra and A. Sen, 2009. In silico
analysis of evolution in swine flu viral genomes through re-assortment by promulgation and mutation. Biotechnology, 8: 434-441.CrossRef | Direct Link |