Assessment of tetanus Immunization among healthcare workers in Mogadishu, Somalia

ABSTRACT

Tetanus is still a major problem in sub-Saharan African countries. This study aims to evaluate tetanus disease and vaccine awareness among healthcare workers in Mogadishu. This descriptive, cross-sectional study was scheduled for January 2–7, 2022. A questionnaire consisting of 28 questions was applied in a face-to-face manner to 418 healthcare workers. Only health workers aged≥18 living in Mogadishu were included. Questions about sociodemographic characteristics, tetanus disease, and vaccines were developed. 71.1% of the participants were female, 72% were ˂25 years old, 42.6% were nursing students, and 63.2% had a university education. It was observed that 46.9% of the volunteers had an income level of <$250, and 60.8% resided in the city center. 50.5% of the participants received a tetanus vaccine in their childhood. Questions to determine participants’ level of knowledge about tetanus and the tetanus vaccine were responded to with an accuracy of between 44 and 77%. Although 38.5% of the participants reported that they were exposed to trauma at least once a day, the rate of those who had three or more doses of the vaccine was only 10.8%. On the other hand, 51.4% reported that they had received training about tetanus and vaccination. There was a significant difference (p < .001) in terms of knowledge level among sociodemographic characteristics. The fear of side effects was the most important reason for not being vaccinated. Healthcare workers in Mogadishu have little awareness of tetanus disease and vaccines. Efforts to improve education and other factors will be sufficient to eliminate the disadvantage brought about by the socio-demographic structure.

KEYWORDS:

• Healthcare workers
• Somalia
• the survey metod
• tetanus
• vaccination

Introduction

A protein neurotoxin generated by the bacterium Clostridium tetani causes the severe but preventable disease known as tetanus.¹ Especially unvaccinated young adults, advanced age groups, and those on immunosuppressives are risk groups for tetanus.² The tetanus mortality rate is high in sub-Saharan African countries: reports have shown a mortality rate of 64% in Nigeria, 47% in Uganda, 43.1% in Tanzania, and 48.5% in Cameroon.³ More than 1,000 newborn tetanus fatalities per 100,000 people were recorded in Somalia, South Sudan, Afghanistan, and Kenya, the countries with the highest prevalence of the disease. The countries with the greatest rates of post-neonatal tetanus mortality (greater than five fatalities per 100,000 people) were Somalia, South Sudan, and Kenya.⁴ There are no data on the tetanus vaccination status in Somalian healthcare workers (HCWs). However, a study was conducted on the tetanus vaccine status in the African community covering 12 countries. It was determined that none of the women of reproductive age in these countries were protected by two or more doses of the tetanus vaccine. As of December 2020, the expected target has not been achieved in Afghanistan, Angola, Central African Republic, Guinea, Mali, Nigeria, Pakistan, Papua New Guinea, Somalia, South Sudan, Sudan, or Yemen.⁵ The final decisions of the World Health Assembly recommended that at least 80% of pregnant women should be vaccinated with at least two doses of tetanus toxoid-containing vaccines and that at least 80% of women of reproductive age in high-risk areas should be vaccinated with at least three rounds of tetanus toxoid-containing vaccine. In Somalia, this rate remained at 58% as of 2019.⁶ Income level directly affects the vaccination rate. Eight of the 12 countries investigated in 2019 were low-income countries, and the remaining four were lower-middle-income countries.⁷ Maternal education, living in the city center, and being born to wealthy families increase the likelihood of children being protected against tetanus at birth.^8,9 Considering that healthcare professionals are role models in vaccination, their views of vaccination and vaccination rates are very important.^10–12 This study aims to evaluate tetanus disease and tetanus vaccine awareness in healthcare workers (HCWs) living in Mogadishu, Somalia.

Materials and methods

Study design and data collection

This descriptive cross-sectional study was planned to be conducted with the students of the Faculty of Health Sciences at Recep Tayyip Erdogan Training and Research Hospital. Somalian HCWs and students receiving health education at the faculty were included in the study. The study was planned to be conducted between 2 and 7 January 2022. A questionnaire consisting of 28 questions was created. The questionnaire was applied to the participants in a face-to-face manner. Participation in the study was voluntary. The participants consisted of specialist doctors, assistant doctors, internship doctors, nurses, nursing students, and paramedics. Those who were <18 years old, Turkish HCWs, and those that were not HCWs were excluded from the study. In addition, participants who did not respond to all the items in the questionnaire form were excluded. The minimum number of participants was determined using the Raosoft calculator.¹³ The calculation was made as follows:

$\mathrm{x}=\mathrm{Z}{\left(\mathrm{c}/100\right)}^2\mathrm{r}\left(100-\mathrm{r}\right)$

$\mathrm{n}=\mathrm{N}\mathrm{x}/\left(\left(\mathrm{N}-1\right){\mathrm{E}}^2+\mathrm{x}\right)$

$\mathrm{E}=\mathrm{Sqrt}\left[\left(\mathrm{N}-\mathrm{n}\right)\mathrm{x}/\mathrm{n}\left(\mathrm{N}-1\right)\right]$

where n: sample size, E: margin of error, N: population size, r: fraction of answers, and Z (c/100) c: critical value for confidence level.

A total of 950 healthcare workers work in our hospital. Moreover, 570 students are actively studying in the Faculty of Health Sciences. Thus, there are a total of 1,520 HCWs. So far, no similar study has been conducted in Somalia. 5% margin of error and 95% confidence interval were accepted. It was determined that there should be at least 307 participants using a 50% precautionary forecast rate. A number above the minimum number was reached by including 418 participants in the study. The data were collected at randomly distributed locations.

Ethical consideration

An application was made to the Ethics Committee of Somalia Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital (Approval no: MSTH/12753). During the application of the survey, personal information such as name, surname, or identification number was not requested from the participants.

Questionnaire design and evaluation

The questionnaire was developed and validated with support from three similar studies.^14–16 The questionnaire was composed of three parts. The first part had seven questions about sociodemographic characteristics (age, gender, profession, education, income, experience, and region). The second part contained 12 multiple-choice questions about tetanus disease and tetanus vaccine (yes, no, and I don’t know). Finally, the last part included nine multiple-choice questions about the vaccination history of the HCWs, their approach to the vaccine, and the difficulties experienced in reaching the vaccine. The questionnaire items were prepared in English, as the majority of Somalian HCWs speak advanced English. Nevertheless, a Somalian health worker, one of the researchers, explained the whole questionnaire to the participants in the Somali language. Thus, there was no language problem. The survey data was first entered into the Excel Program. Then, the answers to the questions were listed as 1, 2, 3, etc. A number was added to each survey. The sum of knowledge scores was calculated in a separate column. Then, 70% of the total score was accepted as the limit, and the participants were divided into two groups: “those with good knowledge” and “those with poor knowledge.” Then, the data were entered into the SPSS program. The frequency data of all answers were determined in the analysis. In addition, the responses in the second part were scored to evaluate participants’ levels of knowledge about tetanus and the tetanus vaccine. In this part consisting of 12 questions, 1 point was given to the correct answer and 0 points to the wrong answer or the answer “I don’t know.” Thus, participants’ knowledge levels were evaluated based on a total of 12 points. Those who scored 8.4 and above (≥70%) were included in the “those with good knowledge” group, while those who scored lower were included in the “those with poor knowledge” group.¹³

Statistical analysis

All data were entered into IBM SPSS Statistics 26.0 (IBM Corporation). Frequencies and percentages were calculated for categorical variables, and means (standard deviation) and medians (interquartile range; IQR) were calculated for continuous variables. While the normal distribution of the data was evaluated using Kolmogorov-Smirnov and histogram tests, homogeneity evaluation was done with Levene’s test. Since the number of participants was>50, the Kolmogorov-Smirnov test was used instead of the Shapiro-Wilk test. The chi-square test, Fisher’s exact test, and Bonferroni test were used to compare categorical data. In addition, the level of significance of the subgroups over the total knowledge score was determined by the Kruskall Wallis test and the Mann-Whitney U test. A p-value of<.05 was considered statistically significant.

Results

Demographic data

A total of 418 Somalian HCWs were included in the study. The sociodemographic characteristics of the participants are given in Table 1 as frequencies and percentages. The majority of the participants were female (71.1%). It was observed that 72% of the participants were ˂25 years old. Nursing students (42.6%) constituted the largest group among the professional groups. When participants’ educational background was examined, it was determined that the majority of the participants (63.2%) received a university education. The income level of 46.9% of the volunteers was <$250. It was seen that 57.7% of the participants had no field experience. When their region of residence was examined, it was seen that 60.8% of them resided in the city center.

Table 1. Sociodemographic parameters, numbers, percentages.

Parameters		N	%
Gender	Male Female	121 297	28.9 71.1
Age	<25 25–35 36–40 >40	301 114 2 1	72 27.3 0.5 0.2
Profession	Doctor Nurse Nursing student Laborant Paramedics	65 148 178 12 15	15.6 35.4 42.6 2.9 3.6
Educational status	School level University level Bachelor’s degree Master’s degree Specialist	5 264 124 20 5	1.2 63.2 29.7 4.8 1.2
Monthly Income status	<$250 $250–500 >$500	196 88 134	46.9 21.1 32.1
Work experience	None 1–4 years 5–10 years >10 years	241 111 58 8	57.7 26.6 13.9 1.9
Region of residence	Village Town City center	92 72 254	22 17.2 60.8

Participants’ level of knowledge about tetanus disease and vaccine

The second part of the questionnaire included 12 multi-choice questions to determine participants’ level of knowledge about tetanus disease and vaccination. The frequency and percentages of the responses are given in Table 2. The rate of correct answers was 75.8% for the first question, 69.1% for the second question, 76.1% for the third question, 77.3% for the fourth question, 61% for the fifth question, 44.7% for the seventh question, 49.8% for the eighth question, 49% for the ninth question, 46.7% for the tenth question, 50% for the eleventh question, and 45.7% for the twelfth question. On the other hand, 50.5% reported that they had been vaccinated in their childhood.

Table 2. Knowledge of tetanus and vaccine.

Questions	Responses	N	%
1. Tetanus enters the body through cuts or wounds.	Yes No Do not know	317 29 72	75.8 6.9 17.2
2. Tetanus can cause serious health problems, such as the inability to open the mouth, difficulty swallowing and breathing, or death.	Yes No Do not know	289 48 81	69.1 11.5 19.4
3. Tetanus is a bacterial infection.	Yes No Do not know	318 44 56	76.1 10.5 13.4
4. Vaccine prevents tetanus.	Yes No Do not know	323 24 71	77.3 5.7 17
5. Tetanus vaccine can be given at any age, including pregnancy.	Yes No Do not know	255 81 82	61 19.4 19.6
6. Five doses of *DtaP are recommended during childhood.	Yes No Do not know	211 60 147	50.5 14.4 35.2
7. A booster dose of the tetanus vaccine is usually recommended every 10 years.	Yes No Do not know	187 82 149	44.7 19.6 35.6
8. A booster dose is given every five years in case of a large or dirty wound or burn.	Yes No Do not know	208 60 150	49.8 14.4 35.9
9. Tetanus vaccine can be given at the same time as other vaccines.	Yes No Do not know	205 101 112	49 24.2 26.8
10. Tetanus vaccine may cause an allergic reaction or an epileptic seizure.	Yes No Do not know	195 88 135	46.7 21.1 32.3
11. In clean and minor injuries, if the immunization status is unknown or < 3 doses, vaccine + TIG is recommended.	Yes No Do not know	209 52 157	50 12.4 37.6
12. If immunization status is unknown or < 3 doses in dirty injuries, vaccine +**TIG is recommended.	Yes No Do not know	191 58 169	45.7 13.9 40.4

(*): Diphtheria Tetanoz acellular Pertussis; (**): Tetanus immunoglobulin.

Tetanus vaccine status of healthcare workers

The last part of the questionnaire aimed to determine the vaccination background of the participants, the reason for the problems in the supply of the vaccine, and their general attitudes toward the vaccine. A total of nine multiple-choice questions were included. The frequency and percentages of the responses are given in Table 3. Due to the civil war in Somalia, exposure to trauma is high because of frequent explosions and injuries. Although 38.5% of the participants reported that they were exposed to trauma at least once a day, it was seen that 31.6% of them did not receive the tetanus vaccine in childhood and 15.8% of them did not know whether or not they received it. It was determined that 39% received the booster dose. In general, the rate of those who had three or more doses of the vaccine was only 10.8%. On the other hand, 23.2% of the participants stated that they could access the vaccine for a fee. Although the tetanus vaccine was administered free of charge to all HCWs in the vaccination nursing unit of our hospital, it was understood that 20.8% of the participants were not aware of it. It was understood that 20.8% of the unvaccinated or insufficiently vaccinated participants did not have it because they were afraid of the side effects of the vaccine. 38.5% of the participants reported that it was compulsory to be vaccinated in the institution where they work or where they receive an education. About half (51.4%) reported that they had received training on the tetanus vaccine.

Table 3. Tetanus vaccine status of healthcare workers.

Questions	Responses	N	%
1. Frequency of clean or dirty injuries?	At least once a day At least once a week At least once a month At least once a year	161 82 95 80	38.5 19.6 22.7 19.1
2. Did you receive a tetanus vaccine in childhood?	Yes No Do not know	220 132 66	52.6 31.6 15.8
3. Have you ever had a booster dose of the tetanus vaccine?	Yes No Do not know	163 174 81	39 41.6 19.4
4. The number of vaccine doses?	I never did One dose Two doses Three doses > Three doses I don’t know	102 54 36 69 45 112	24.4 12.9 8.6 16.5 10.8 26.8
5. Vaccine was free or paid?	Paid myself Free Do not know	97 177 144	23.2 42.3 34.4
6. Availability of the tetanus vaccine at the workplace or educational institution?	Yes No Do not know	241 90 87	57.7 21.5 20.8
7. Reasons for not being vaccinated?	Expensive Afraid of the side effects of the vaccine The vaccine is not easily available Not necessary Lack of time Because of religious and cultural values Unanswered	50 87 67 46 33 23 112	12 20.8 16 11 7.9 5.5 26.8
8. Is tetanus vaccination mandatory in your institution or education unit?	Yes No Do not know	161 177 80	38.5 42.3 19.1
9. Is vaccination training given in the health institution or education unit you work for?	Yes No Do not know	215 146 57	51.4 34.9 13.6

Evaluation of knowledge levels with the chi-square (χ²) test

Twelve questions were prepared to evaluate participants’ knowledge levels about the tetanus disease and vaccine. Each correct answer was worth 1 point (0–12 points). Participants with ≥8.4 points (≥70%) were categorized as “having good knowledge,” while those with <8.4 points (<70%) were categorized as “having poor knowledge.” When sociodemographic variables and knowledge levels were compared in the chi-square test, it was determined that there was a significant difference between all parameters in terms of knowledge levels (p < .001). In addition, the Kruskall Wallis test and Mann-Whitney U test were applied to evaluate the level of significance among subgroups over the total knowledge score. In the 25–35 age group, the knowledge score was statistically significantly higher than in the other age groups (p < .001). Similar significance was found in men compared to women, in doctors compared to other occupational groups, and in nurses compared to nursing students and paramedics (p < .001). Knowledge scores were statistically significantly higher in laborants than in paramedics, in those with Bachelor’s degrees and Master’s degrees than in university students, in those with an income of >$500 than in those with less income, in groups with professional work experience than in groups with no work experience, and in those living in the city center than in those living in rural areas (p < .001) (Table 4).

Table 4. Comparison of sociodemographic characteristics and level of knowledge about tetanus and vaccine (χ²).

Variables			Good Knowledge (≥%70),		Poor Knowledge (<%70),		p values
			N	%	N	%
Overall	Categories		123	29.4	295	69.6	-
Gender	Male		53	12.7	68	16.3	<.001
	Female		70	16.7	227	53.3
Age	<25		48	11.5	253	60.5
	25–35		75	17.9	39	8.5	<.001
	36–40		0	0	2	0.4
	>40		0	0	1	0.2
Profession	Doctor		40	9.5	25	6.5
	Nurse		54	12.9	94	20
	Nursing student		23	5.5	155	37	<.001
	Laborant		5	1.3	7	1.6
	Paramedics		1	0.2	14	3.2
Education	School level		0	0	5	1.3
	University level		37	8.8	227	54.2
	Bachelor’s Degree		70	16.8	54	12.1	<.001
	Master’s Degree		13	3.1	7	1.6
	Specialist		3	0.7	2	0.4
Income	<$250		32	7.7	164	39.2
	$250–500		28	6.6	60	14.3	<.001
	>$500		63	15.1	71	16.1
Region of Residence	Village		10	2.4	82	19.6
	Town		21	5	51	12.2	<.001
	City center		92	22	162	37.8
Experience	None		37	8.8	204	48.8
	1–4 years		48	11.5	63	13.6	<.001
	5–10 years		33	7.8	25	6.5
	>10 years		5	1.3	3	0.7

Evaluation of none-vaccination by the chi-square (χ²) test according to sociodemographic characteristics

Participants who were not vaccinated or who had a missing dose were asked a question about the missing dose or the reasons for not being vaccinated. Their responses were analyzed with the chi-square (χ²) test and Bonferroni test according to sociodemographic characteristics (Table 5). When the answers were evaluated, the fear of side effects emerged as the most important reason. Difficulties in accessing the vaccine and lack of time were other important reasons. There was a significant difference in terms of the reasons for the lack of vaccination among gender (p < .008), age (p < .001), profession (p < .001), education (p < .001), experience (p < .001), income (p < .001), and region (p < .002) subgroups.

Table 5. Evaluation of none-vaccination according to sociodemographic characteristics (χ²).

Variables		Expensive	Afraid of Side Effects	Not Easily Available	Not Necessary	Lack of Time	Religious and Cultural Factors	Total (%)	p-value
Gender (%)	Male	17.4	25.6	24.4	14	14	4.7	100	.008
	Female	15.9	29.5	20.9	15.5	9.5	8.6	100
Age (%)	<25	17	29.8	20	16.2	8.9	8.1	100	<.001
	25–35	14.7	25	29.4	10.3	14.7	5.9	100
	36–40	0	0	0	50	50	0	100
	>40	0	0	0	0	100	0	100
Profession (%)	Doctor	10.6	40.4	17	8.5	19.1	4.3	100	<.001
	Nurse	22.5	28.4	16.7	14.7	9.8	7.8	100
	Nursing student	15	25	27.1	16.4	7.9	8.6	100
	Laborant	14.3	14.3	42.9	0	28.6	0	100
	Paramedic	0	30	10	40	10	10	100
Education (%)	School Level	20	40	20	0	20	0	100	<.001
	University	16.3	25.7	21.3	17.8	9.4	9.4	100
	Bachelor’s Degree	17.6	30.6	23.5	10.6	14.1	3.5	100
	Master’s Degree	0	63.6	27.3	0	0	9.1	100
	Specialist	33.3	0	0	33.3	33.3	0	100
Experience (%)	None	19.4	20.6	22.6	16.8	11.6	9	100	.001
	1–4 years	20.7	27.6	22.4	20.7	8.6	0	100
	5–10 years	8.6	41.9	20.4	8.6	10.8	9.7	100
	>10 years	17.5	27.9	23.5	15.3	8.7	7.1	100
Income (%)	<$250	14.1	28.2	20.5	15.4	12.8	9	100	<.001
	$250–500	15	35	20	12.5	12.5	5	100
	>$500	20	0	0	20	40.0	20	100
Region (%)	Village	27.1	21.4	21.4	10	11.4	8.6	100	.002
	Town	14.3	28.6	26.5	12.2	8.2	10.2	100
	City center	12.8	31	20.9	17.6	11.2	6.4	100

Discussion

Although the risk of exposure to trauma is very high in Mogadishu, where civil war and explosions are experienced intensely, there is no study exploring the tetanus vaccine status in HCWs. In our study, a serious insufficiency was found in full-dose vaccination. The main reasons for this in Somalia are the fear of side effects, cultural and religious factors such as social opposition to vaccination, and financial inadequacy. Most of the participants are not aware of the fact that free vaccines can be obtained from our institution. Living in rural areas is another important disadvantage. According to World Health Organization data, 26–70% of the Somali population is poor. 2.6 million people have been displaced by terrorism. Vaccine insufficiency is inevitable in these people, who have difficulties in accessing even basic health services.¹⁷

A meta-analysis searched PubMed/MEDLINE online, ScienceDirect, Hinari, Hinari, Google and Google Scholar databases and reviewed 199 published studies on tetanus toxoid vaccine in Ethiopia, Somalia’s neighbor. 14 studies were included. The rate of those who received at least two doses of the tetanus vaccine was found to be 52.2% (95% CI: 42.47–61.93). Antenatal treatment (OR = 7.8 (95% CI: 3.2, 19.2)), difficulty in accessing healthcare facilities (OR = 2.64 (95% CI: 1.1, 6.6)), women’s educational background (OR = 4.7 (95% CI: 2.07, 9.56)), and their husbands’ educational background (OR = 2.995 (95% CI: 1.194, 7.512)) were significantly associated with getting at least two doses of the tetanus vaccine.¹⁸ Maternal tetanus and neonatal tetanus still occur in nine sub-Saharan African countries. There are many factors that affect access to vaccines. In a study conducted with women of childbearing age in rural areas in Nigeria, three groups of women were given financial aid to encourage vaccination. The probability of being vaccinated was found to be higher in the two groups with more financial aid than in the group with less money. Transportation costs were reported as one of the major barriers to accessing the vaccine.¹⁹ In a review examining the efforts to develop vaccine strategies in sub-Saharan African countries, it was reported that factors such as low birth age, relatively good welfare level, employment of women, and frequency of prenatal follow-ups contributed positively to the efforts in Kenya. In Ethiopia, factors such as the large unvaccinated population, deficiencies in reporting, the fragility of the health system, and resource limitations were emphasized. In Nigeria, shortcomings in notifications, the lack of information on the vaccination schedule, deficiencies in the registration system, and the necessity of referral to a doctor for vaccination were reported as the disadvantages. The lack of community involvement was also found to be an important limiting factor. Emphasis was placed on raising awareness as a society to change or influence women’s attitudes and beliefs toward vaccination. It was also concluded that improving vaccine accessibility, affordability, availability, and accommodation would increase vaccination rates.²⁰ In another review that analyzed studies on vaccine distribution systems in Nigeria, Benin, and Mozambique, it was shown that outsourcing vaccine logistics to the private sector contributed to the improvement in vaccine distribution costs and backup in vaccine warehouses.²¹

Even in developed countries, tetanus vaccine awareness among HCWs is lower than we expected. In a survey study with 197 HCWs in China, only 21.3% of physicians had a booster dose. In addition, only 28.9% reported that they had received training on vaccination. Only 14.2% of respondents confirmed that the tetanus vaccine was available at their institution. As a result, in this study conducted with emergency physicians, it was understood that patients were not vaccinated sufficiently because the physicians did not have enough knowledge. It was also determined that even physicians did not receive sufficient doses of vaccination.¹⁴ In a survey study conducted with a volunteer group of 336 people consisting of doctors, nurses, and support staff in Turkey, the participants did not have enough information about the vaccination of women between the ages of 15 and 49 and the need for a booster tetanus vaccine every 10 years. In addition, it was understood that the nurses had a significant lack of knowledge about booster doses.²² There are different data on the vaccination attitude, knowledge level, and vaccination rate of HCWs in survey studies conducted with HCWs in different countries.^23–26

In our study, it was determined that sociodemographic characteristics affected knowledge levels (p < .001). Tetanus and vaccine knowledge scores were higher in the middle-aged group, males, those living in the city center, and those with more work experience. These results indicate the effect of vocational education quality and the undeniable impact of financial means. When our study and similar studies are evaluated, the main factors related to inadequate vaccination in African countries are shown in Figure 1 under nine titles.

Figure 1. Factors affecting vaccination in Sub-Saharan Africa.

The development of plans for the solution of these problems by the health units of the countries, especially Somalia, will contribute greatly to vaccination.

The study has some limitations. First, the survey questions were developed using similar publications instead of an internationally valid scale. Second, the sample consisted mostly of participants living in Mogadishu. Therefore, the results may fail to reflect the whole country. Third, the majority of the respondents are female. This is because most of the students at the Faculty of Health Sciences are female. Hence, the study sample may fail to represent the general population. Future studies could be done with more favorable ratios of male and female participants. Fourth, the inclusion of allied HCWs and students without work experience may have affected homogeneity. To reduce the risk of bias in responding, the questionnaire was administered without collecting participants’ personal information. In addition, necessary explanations regarding confidentiality were made to the participants.

Conclusion

HCWs should be role models for other society members about vaccination. Yet, it was determined that vaccination awareness and vaccination rates were quite low among the HCWs in Mogadishu. It was understood that the sociodemographic structure of the HCWs in Mogadishu significantly affected the awareness of the vaccine. It was also seen that there was a serious need for planning training programs on vaccines. Besides, the lack of knowledge about vaccine availability among many HCWs was noticed. Somalia has difficult living conditions due to its geography and lack of income sources. However, a high rate of tetanus vaccination is possible, especially in HCWs, with simple measures such as reevaluation of education programs and free availability of the vaccine. In our study, the main factors affecting vaccination were revealed. The development of plans for the solution of these problems by health and education institutions will significantly contribute to increasing the rate of vaccination. Since this survey study was only applied to HCWs, large-scale studies including other segments of society would provide more precise data.

Acknowledgments

We would like to thank the staff of the Faculty of Health Sciences and infection control committee nurses for their support in the application of the survey.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

We declare that no support has been received for the study from any institution.