The influenza vaccine for nursing and care professionals at emergency services in Flanders

ABSTRACT

Background: The Belgian Superior Health Council recommends seasonal influenza vaccination for people working in the health care sector in order to reduce the risk of the influenza virus being transmitted to people at risk. The aim of this study is to provide more insight into the current vaccination rate in nurses and health care professionals in emergency services in Flanders. In addition, the influence of influenza vaccination on absenteeism will be investigated, as well as the motivation to get vaccinated or not.

Methods: A quantitative multicentre, cross-sectional study was carried out in which

nurses and health care professionals in emergency services in Flanders were questioned by means of an online questionnaire.

Results: The survey of nurses and health care professionals in Flanders from 2018 shows that 54% (294/548) gets vaccinated in this year. Respondents who have been vaccinated report a lower absenteeism due to influenza compared to health workers who do not get vaccinated. There is a lack of general knowledge about influenza and vaccination. Thirty-four percent of nurses and health care professionals in emergencies do not know the correct definition of influenza. The main reasons for being vaccinated are: to protect oneself (27%), family members (21.5%) and patients (16%). Reasons for not getting vaccinated are: never having had the influenza before (30%), believing you get the influenza because of the vaccination (12%), no belief or trust in the vaccine (19%). Three percent of respondents who received the influenza vaccine were absent due to flu. The absence due to influenza was higher among the respondents who were not vaccinated, namely 11%. Being vaccinated for influenza or not has been associated with being absent for influenza.

Conclusions: Given that there is a lack of general knowledge about influenza and its vaccination, the vaccination campaigns should cover this knowledge gap. Efforts to convince both nursing and care professionals about the protective role of the Influenza vaccine. These efforts can improve the influenza vaccination coverage rate and consequently minimize the absenteeism.

Abbreviations: WHO: World Health Organization; UZA: University Hospital of Antwerp; SPSS: Statistical Package for the Social Sciences

KEYWORDS:

• vaccination
• influenza
• absenteeism
• nursing and care professionals
• emergency services
• flanders

Background

The World Health Organization (WHO) defines influenza as follows: “Influenza is a viral infection that mainly affects the nose, throat, bronchi and sometimes the lungs. This infection usually lasts about a week and is characterized by a sudden high fever, muscle pain, headache, severe malaise, nonproductive cough, sore throat and rhinitis”.¹

Healthcare workers are much more likely to come into contact and be infected with the influenza virus than the average healthy adult.² This chance obviously depends on the severity of the epidemic and the department where health workers work. Nurses and health care professionals working in a clinical environment are more likely to be infected than their colleagues in a non-clinical environment. In a clinical environment, the risk of infection is greatest in the emergency department, because nurses and health care professionals are more likely to come into contact with patients who have not received a definitive diagnosis. An estimated 5.8 times a year a health worker in a nursing home is exposed to the influenza virus. Although not every exposure leads to an effective infection, it is estimated that one in four health workers could be infected during a mild influenza season. This is much higher than the 10% in the general population.³

Influenza vaccination reduces the risk of infection and protects the health care worker himself, his colleagues and patients.⁴ Influenza vaccine effectiveness depends on the personal characteristics of the vaccinated individual and the closeness of matching between the vaccine and the prevalent strains of the virus. From this point of view, vaccination is recommended for all healthcare workers.^2,4

To this end, the Flemish vaccination target sets a vaccination rate of at least 80% for all hospital personnel.⁵

In medical literature, there is little to be found about the level of vaccination and its influence on absenteeism among nurses and health care professionals in emergency services in Flanders. Little is also known about the reasons for whether or not to get vaccinated. The aim of this study is to gain more insight into this.

Methods

Study sample

There were 56 flemish hospitals contacted to participate in this study, 41 confirm their participation, 6 hospitals refused and from 9 institutions we did not receive an answer.

Nurses and health care professionals with at least 2 years of work experience were included. The sample was calculated by the formula (the population size of emergency staff 1200. Sample size at one confidence level of 95%), the minimal sample size needed for the present study was 300 participants.

Study design

A quantitative multicentre, cross-sectional study was carried out in which nurses and health care professionals in emergency services in Flanders were questioned by means of an online questionnaire.

Questionnaire

The questionnaire was drawn up via the Qualtrics® program and consists of five blocks: demographic data, reasons for whether or not to get vaccinated against influenza, general knowledge about influenza and its campaign, vaccination status and absenteeism due to influenza-like symptoms of the last 2 years. The latter was questioned on the basis of the WHO definition of influenza. As many closed-ended questions as possible were used with different answer options. The questionnaire was based on information needed to answer the research questions. The results from similar studies were also taken into account.^1,4,6,7

Respondents were followed up on the basis of the number of response forms received. The aim was to achieve a response rate of at least 35% per participating emergency department. If the response rate was too low, the questionnaire was once again distributed to the target group. Data analysis was carried out using the Statistical Package for the Social Sciences (SPSS) version 23 program. Using descriptive analyses, the database was checked for missing values, double response forms of the same respondent and errors. Only fully completed response forms were retained for further statistical analysis. A significance level of p < .05 was used.

Results

After completion of the online survey, 739 participants were registered, the expected response rate was 300 participants. After checking the demographic data for inclusion and exclusion criteria, 548 response forms were selected. The research population is shown in Table 1.

Table 1. Research population and demographic data

Research population and demographic data
N = 548
	%
Female	61%
Age category
20–35 36 – 50 51–65	37% 39% 24%
Educational level
Bachelor of nursing with special professional title “emergency and intensive”	85%
Others	15%
Jobtime
Full time	62%
Mean (SD)
Years active as a health worker	19y (11)

It is important to know that the vaccination policy for seasonal influenza is not mandatory for the personnel of the emergency services in Flanders, but the trivalent vaccine is offered free of charge.

General knowledge of influenza

The WHO definition of influenza is known by 66% (n = 360) of the respondents. Eighty-five percent (n = 471) of the respondents know that they can infect others with influenza during the incubation period. Only 12% (n = 65) of health workers do not know that they should be restricted from work in case of fever and coughing and would therefore continue to work with the symptoms of influenza. When asked whether pregnant women should be given the influenza vaccine, 75% (n = 412) answered positively and in this way correctly.

Of out the 548 respondents, 27% (n = 147) answered the four knowledge questions above correctly. The questions and percentages for the different answer categories are shown again in Table 2.

Table 2. General knowledge of influenza

N = 548	n	%
(1) According to the WHO, influenza is defined as
Correct definition known (Infection, lasts about a week, and is characterized by sudden high fever, muscle soreness, headache, severe malaise, nonproductive cough, sore throat and rhinitis)	360	66
Definition partly known (Infection, lasts more than 2 weeks, and is characterized by sudden high fever, muscle soreness, headache, severe malaise, nonproductive cough, sore throat and rhinitis)	86	15
Definition not known (Infection, lasts about a week, and is characterized by only high fever and muscle pain)	102	19
Total	548	100
(2) Can I infect others with influenza during the incubation period?
Correct answer known “Yes”	471	85
Correct answer not known “No”	38	7
“I don’t know”	49	8
Total	548	100
(3) With the symptoms of flu, would I continue to work?
Correct answer not known “Yes”	65	12
Correct answer known “No”	317	58
“Uncertain”	166	30
Total	548	100
(4) Can a pregnant employee get the influenza vaccine?
Correct answer not known “Yes”	412	75
Correct answer known “No”	48	9
“I don’t know”	88	16
Total	548	100

Vaccination status

For the influenza season 2017–2018, 54% (n = 294) of the nurses and health care professionals at emergency services in Flanders have been vaccinated. There is no association between vaccination status and age (p value = 0,404). Moreover, no statistical significance (p value = .929) can be observed between education level and vaccination. The fact that information about influenza and its consequences is provided by the employer or not was not significantly different for vaccinated versus non-vaccinated employees. The knowledge of the Flemish government’s “Protect Yvette” influenza campaign also did not result in a significant difference. These influenza vaccination campaigns in health care institutions primarily aim to avoid the transmission of the influenza virus from the health care workers to the patient. The emphasis is on both knowledge and practical organization of a vaccination campaign.

Absenteeism

There is a statistically significant difference (p < .001) between the vaccinated (54%) and non-vaccinated (46%) staff with respect to absenteeism. The respondents who received the influenza vaccine were absent due to influenza in the last 2 years was 3% (n = 10). Among the respondents who were not vaccinated, the absence due to influenza was higher, at 11% (n = 28).

Also 12% of health workers continue to work with the symptoms of the influenza, 30% of the respondents are insecure that they will go to work and 58% will be absent from work.

Reasons for whether or not to get vaccinated

The five main reasons for getting vaccinated are: not having to go through the influenza yourself (27%), to protect family members (21.5%), to protect the patient (16%), obliged by the employer (14%) and social pressure (7%).

The main reasons among the respondents for not getting vaccinated were “Never had a influenza” 30%, “No specific reasons” (24%), “No faith or confidence in the vaccine” (19%) and “I get a influenza from this vaccination” with 12%.

Discussion

The results of this study are in line with the results of the Flemish Community study, which shows that only 1 in 2 of all staff in hospitals are vaccinated against influenza every year.⁵ An approach to increase the vaccination status is necessary. Vaccination for influenza is not mandatory in Belgium. An obligation for healthcare workers can increase vaccination coverage.

The knowledge about how and why getting vaccinated is a strong influence factor for whether or not to be vaccinated.⁸ Therefore, it is opportune for nursing and care professionals in the emergency department to focus on a better knowledge of the causes and consequences of influenza. Thats also a conclusion from Oguz et al. (2019) that an onsite vaccination campaign, influenza vaccination coverage significantly improved among professionals. ⁹

The effectiveness of influenza vaccination in high-risk individuals should also be emphasized in future influenza vaccination campaigns.^8,10 It is remarkable that 61% of non-vaccinated people were sufficiently informed. These figures show that responding to the reasons for vaccinating – protecting oneself, family members and patients – can be an added value. On top of that, it will be important in the campaign to focus on the credibility/confidence of the vaccine. No belief or trust in the vaccine is one of the biggest factors for not being vaccinated.¹¹

According to Pereira et al. (2017), a 10% increase in the number of vaccines would reduce absenteeism by 10%.¹² Raising the vaccination status among Flemish nurses and health care professionals in emergency departments could therefore probably also contribute to lower absenteeism. As a result, the spread of influenza will also decrease among colleagues and family, and absenteeism may decrease even further. It is important to note here that absenteeism due to influenza has been determined by a self-questioning of the health care worker. A more objective investigation into the absence of influenza related to the data from the human resources department could provide even more clarity.

The results of this study indicate a direction that nurses and health care workers can make a strong contribution to the fight against influenza inside and outside the hospital by getting vaccinated. These results should be interpreted with caution because of the self-report of absenteeism. In addition, the importance of preventing and minimizing the spread of influenza and a high influenza vaccination rate is underlined. Responding to professional responsibility does not add value (Smith et al., 2016). More, a targeted awareness-raising and gaining the trust of the nurses and health care professionals will be necessary to increase the influenza vaccination rate.

Conclusions

This research shows a lack of general knowledge about influenza and its vaccination among nurses and health care professionals. This should be interpreted with caution because of the self-reporting of absenteeism and the non-response rate. The authors would like to stress the importance of preventing and minimizing the spread of influenza by utilizing higher influenza vaccination rates among nurses and health care professionals in Flemish emergency departments. Responding to professional responsibility does not seem to be an added value.¹³ Targeted awareness-raising and winning the confidence of nursing and care professionals will be necessary to increase the seasonal vaccination coverage rates.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Authors contributions

MS coordinated the study. As principal investigators, MS and HV were responsible for all scientific aspects of the work. All authors were involved in the preparation of the research project, the analyses and the drafting of the manuscript.

HV supervised analysis of the databases and the formulation of results.

PVD and GVH provided scientific support during the various phases of the study. All authors provided feedback and made revisions to the manuscript.

Competing interests

The authors declare that they have no competing interests.

Declarations

Ethics and consent to participate

The research protocol and the questionnaire were approved by the Ethics Committee of the University Hospital of Antwerp (UZA) with the number 17/46520. Participation in the study was non-binding and a digital informed consent was included in the questionnaire. The participants were made anonymous.

After the central ethical committee of the UZA had approved this multicentre study, written contact was made with 56 managing boards of Flemish hospitals that have an approved emergency department. This list of recognized emergency services was obtained via the Federal Public Health Service. The necessary information about the purpose and progress of the research and the digital link to the questionnaire were then provided to the head nurses of the participating hospitals, who in turn invited the respondents via e-mail. The survey covered the period from 14/01/2018 to 28/02/2018.

Acknowledgments

Many thanks to all fellow researchers who participated in this research study: Guido Van Hal (GVH), Herman Vandevijvere (HV), Pierre Van Damme (PVD)

Additional information

Funding

The authors declare that they do not receive any research funding for the article.