Vaccination of Chinese health-care workers calls for more attention

ABSTRACT

Though China’s health-care workers (HCWs) had totaled as many as 12.3 million by the end of 2018, vaccination rates among them are still low or just moderate. There are few vaccination programs specifically for them. Neither targeted systematic recommendations nor effective incentives are in place. The HCWs also have some knowledge or awareness gap in vaccination. Moreover, HCWs’ exposure to and infection risk of vaccine-preventable diseases (VPDs) mount up, as a great number of unvaccinated Chinese patients crowd in a few large hospitals. So does the chance of a nosocomial VPDs outbreak. Therefore, receiving vaccines is an essential part of infection prevention and control for HCWs. China should pay more attention to the challenges and take substantial measures to address it in the “Healthy China” agenda.

KEYWORDS:

• Health-care workers (HCWs)
• vaccine
• vaccination
• vaccine-preventable diseases (VPDs)
• infection prevention and control

Health-care workers (HCWs) are usually at high risk for exposure to (and possible transmission of) vaccine-preventable diseases (VPDs), due to their frequent contact with patients or infectious agents from patients.¹ A systematic review showed that influenza infection rate among unvaccinated HCWs was 18.7% (95%CI,15.8%–22.1%) in each influenza season. The incidence of this group was 3.4 (95% CI, 1.2–5.7) times of that among unvaccinated healthy adults.² Moreover, the risk of hepatitis B virus (HBV) infection among HCWs was 2 ~ 10 times higher than the population level.^3,4 And a study revealed that HCWs face 19 times higher risk of getting measles than the general people.⁵ Therefore, cases of occupationally acquired VPDs among HCWs are common.^1,6 It is necessary for China, a country with the largest health workforce in the world (12.3 million HCWs by the end of 2018⁷), to build up its capacity in nosocomial infection control, better protect the HCWs, and reduce transmission of VPDs.

Vaccination programs are proved to be effective strategies for VPD prevention and control among HCWs.^1,6,8 However, the vaccination rates of Chinese HCWs are still low or just moderate at present.^9-11

A literature review indicated that the median uptake rate of influenza vaccine was 15.2% (7.54–55.57%) among HCWs in China.⁹ The highest rates were the coverage of H1N1 influenza vaccine in H1N1 outbreak of 2009–2010, such as 55.57% in Shenzhen¹² and 25% in Beijing.¹³ We conjectured that the outbreak of H1N1 influenza aroused more HCWs’ attention to relevant vaccination at that time. But the higher rate did not sustain. After the outbreak, most relevant studies concentrated on HCWs’ vaccination against seasonal influenza, and the reported rates were just around 10%.^14-17 The latest studies indicated that influenza vaccination rates of HCWs were below 10% in China,^16,17 while it was 78.4% in the United States in 2017–2018.¹⁸ The vaccination rate of HepB among Chinese HCWs is higher than that of flu vaccine, but still much lower than the level in the U.S., France, Australia, and other developed countries, which is above 90%.¹⁰ The self-reported vaccination rate of at least one-dose HepB was about 39.5–86.36%¹⁰ and studies found 40.42–59.70% of Chinese HCWs completed a full course of HepB vaccination.^19,20 A study showed that about 30% HCWs with occupational blood-borne exposure had not been vaccinated against HBV.²¹ Several studies on coverage of measles-containing vaccine (MCV) among HCWs showed a suboptimal uptake rate: around a half of participants had been vaccinated against measles.^22-24 However, one of these studies showed that, out of those who had not received MCV or those vaccination status had been unknown before they were employed by hospitals as HCWs, only 18.4% (48/261) were vaccinated afterward.²² There are few studies or reports on coverage of other vaccines among HCWs in China.

We argue that the insufficient vaccine uptake among Chinese HCWs is mainly because there are few vaccination programs and strategies specifically for HCWs in place. By contrast, some countries or regions have made massive efforts on such kind of programs. In the U.S., HCWs were recommended to vaccinate against Hepatitis B in 1982, just 1 year after the vaccine was available.¹ Advisory Committee on Immunization Practices (ACIP) published the Immunization Recommendations for HCW in 1997 and established the ACIP Immunization of Healthcare Personnel Working Group in 2008, which is a sub-group under the Adult Immunization Working Group to update those recommendations. The first update was released in 2011.¹ In Europe, most countries enforce laws and regulations to improve occupational vaccination for HCWs. A health-care worker who does not get mandatory vaccination may be fined or moved to a position with low infection risk or without direct contact with patients.⁶ The Japanese Society for Infection Prevention and Control (JSIPC) Guidelines clearly require that HCWs’ antibody titers against VPDs including measles, mumps, rubella, and varicella-zoster must be higher than laboratory thresholds.²⁵

However, in China, relevant policies and their implementation face a series of challenges.

First, there are few systematic recommendations or requirements on HCWs’ vaccination. Relevant policies are now scattered in some technical guidelines on vaccination against individual disease, or in governmental documents designed to control some specific VPD. For example, it is recommended that HCWs are a prioritized group of influenza vaccination in the Technical Guidelines for the Application of Seasonal Influenza Vaccine in China (2014 ~ 2015).²⁶ Similarly, people under the risk of occupational exposure, such as medical students and medical workers exposed to blood, are recommended to be vaccinated against hepatitis B according to the Technical Guidelines for Adult Hepatitis B Immunization in China.²⁷ The Notice on the Prevention and Control of Measles issued in 2015 proposed HCWs aged below 50 to be vaccinated with at least one dose of MCV on an informed and voluntary basis, if they did not have a history of measles or measles vaccination or the history was unknown. However, there are no policies and recommendations specifically for HCWs, which may make this issue difficult to get the attention it deserves.

Second, financial support and effective incentives to vaccinate HCWs are weak. As the vaccines recommended to HCWs are not covered by EPI (National Expanded Program on Immunization), their vaccination is on a voluntary basis and paid out of pocket, which partly explains the low uptake rate. By contrast, EPI vaccines achieve coverage of up to 90%, because they are compulsory and free for target population–infants and children.²⁸ Studies in other countries showed that some non-compulsory vaccination policies could also effectively improve the uptake rate among HCWs, including publicity campaign in hospitals, mobile vaccination vehicles, free vaccination services, education and training on VPDs.^29-31 However, such activities and incentive mechanisms are in shortage in China.¹¹ Even if there are some, the implementation is quite poor. For example, China issued a document on 22 October 2018 (the 2018 document) which required (not just recommended as before) HCWs to vaccinate against influenza, and health-care facilities to provide the services to their staff free of charge.³² We conducted a qualitative study 3 months later and found that all six HCW participants did not know this document.¹¹ Eight months later (covering two flu seasons: winter and spring), we conducted a survey in two tertiary hospitals located in an economically developed city in Southern China and found that only 6.55% (27) were vaccinated against influenza among 412 participants. And the two surveyed hospitals did not delivery influenza vaccination services for free.

Third, Chinese HCWs have some misunderstandings on vaccination. As non-EPI vaccines are not compulsory, HCWs can decide whether to get them or not substantially based on their own perceptions toward vaccination.¹¹ But their knowledge or awareness of VPDs and vaccination is limited. Two studies in 2016 found that just 9.5–30.91% front-line HCW participants had the right awareness of influenza vaccine, and more than 40% HCW participants did not think influenza vaccine was safe and effective.^16,17 A multi-center study in three provinces of China in 2018 indicated that more than 20% HCWs were not sure about the effectiveness of the HepB vaccine.¹⁹ Moreover, HCWs are more likely to know the cases and incidents of side effects of vaccination or immune failure, as well as some accidents in vaccine R&D (research and development) and production. They may even personally deal with those cases and incidents. So they are likely to have some bias on risks and benefits of vaccination,³³ which may lead to negative attitudes toward vaccination and then influence public conceptions toward vaccination.^19,34 The cognitive bias and the negative influences may be more pronounced in China, due to vaccine-related emergencies now and then in recent years.

Moreover, the crowded environment in hospitals and low or unsatisfactory vaccination rate among the general population make the vaccination of HCWs in China more significant and urgent. First, patients concentrate in non-primary-care institutions such as county-level, municipal-level or provincial-level hospitals due to lack of mature gate-keeping system in China,³⁵ causing an overcrowded clinical environment in those hospitals. The outpatient visits per day in most county-level hospitals or above average over 1000 in China.³⁶ In some large provincial-level hospitals there are more than 10, 000 visits a day.³⁶ Most of the patients have not received non-EPI vaccines (almost all vaccines for people ≥6 years are not covered by EIP). For example, influenza vaccine uptake is just 1.9% among the general population in China,³⁷ however, hospitals in major cities are full of patients with flu symptoms in every flu season. The varicella vaccine is still not included in EPI, and its overall coverage among Chinese children is just 61.1% (95%CI: 55.7–66.5%).³⁸ EPI expanded to children HepB vaccine in 2002, and covered children measles, mumps, and rubella conjugate vaccine (MMR) in 2008. As a result, people born before 2002 or 2008 may not receive these vaccines adequately. Eula Biss indicates in her book On Immunity: An Inoculation that our physical health depends on the choices made by others.³⁹ Therefore, infection control in hospital partially depends on the overall population’s vaccination status. In an environment with such a high density of sick susceptible people and strong population mobility, some air-borne infectious diseases, such as influenza, measles, mumps, rubella, and varicella, are easy to spread. It also represents a much higher risk of HCWs exposure to and infection with VPDs as well as the risk of nosocomial VPDs outbreak.³³ Secondly, unvaccinated HCWs may become a source of virus transmission. It was indicated that as high as 75% HCWs with influenza symptoms kept working on their positions.⁴⁰ It may also be hard for Chinese HCWs to take sick leave when they acquired some VPDs like influenza or were at the early stage of some VPDs, given a considerable shortage of health professionals and the overloaded environment in hospital in China.^41,42 Without effective protective measures, their patients and companions of the patients, especially vulnerable ones like the elderly and the kid, are exposed to high risk of infection.⁸ HCWs are also supposed to have a moral and ethical responsibility for preventing the spread of VPDs to patients.⁴³ Therefore, vaccination of HCWs is an essential part of infection prevention and control for themselves and other people.

Nowadays, China has a critical opportunity to address the above-mentioned challenges – the “Healthy China Strategy”. It is the core of the Chinese government’s agenda in the health sector. The Outline of Healthy China 2030 Planning indicates that “health” has become a national political priority. HCWs’ vaccination has every reason to be on the agenda. The United States’ Healthy People 2030 definitely set the target of vaccination for HCWs. Systematic vaccination strategies or recommendations for HCWs are badly needed in China, which may depend significantly on political leaders’ attention and commitment on this issue. Then, incentive mechanisms (free service, for example) or some other interventions (effective publicity for instance) should be developed to ensure the implementation of the vaccination strategies. To the end, efforts from the top all the way down to the bottom are necessary. It is not too late for relevant departments including National Health Commission and China CDC to take HCWs’ vaccination seriously and address the challenge. Vaccination has been regarded as the top strategy to improve the preparedness for a global influenza pandemic.⁴⁴ It is believed that with a strong administrative system, China has the capacity of developing and implementing appropriate strategies to protect HCWs and the general public from VPDs.

Disclosure of potential conflicts of interest

The authors declare they have no competing interests.

Ethics Statement

The study was approved by the Ethics Committee of Anhui Medical University.

List of abbreviations

HCWs:	=	Health-care workers
VPDs:	=	vaccine-preventable diseases
HBV:	=	hepatitis B virus
HepB:	=	hepatitis B vaccine
EPI:	=	National Expanded Program on Immunization
MMR:	=	measles, mumps and rubella conjugate vaccine
MCV:	=	Measles containing vaccine.

Availability of data and materials

Data can be made available by request.

Authors contributions

WL and ZX designed the study, discussed the framework of the manuscript. WL, ZX, and CG contributed to drafting the paper. All authors read and approved the final manuscript.

Additional information

Funding

This study was supported by Grants for Scientific Research of BSKY [XJ201814] from Anhui Medical University.