|Year : 2014 | Volume
| Issue : 3 | Page : 192-197
Pandemic influenza A (H1N1) vaccination among libyan health care personnel: A cross-sectional retrospective study
Nagiat Tayeb Hwisa, Prakash Katakam, Babu Rao Chandu, Mraa Hazim Ismael, Abdalwahab Bader
Department of Pharmacology and Biochemistry, Faculty of Pharmacy, University of Zawia, Az Zawiyah, Libya
|Date of Submission||08-Apr-2013|
|Date of Decision||17-Aug-2013|
|Date of Acceptance||29-Sep-2013|
|Date of Web Publication||24-Jun-2014|
Department of Pharmacology and Biochemistry, Faculty of Pharmacy, University of Zawia, Az Zawiyah
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Vaccination rate among health-care personnel's (HCPs) are not promising notwithstanding the World Health Organization campaigns over three decades resulting in compromising patient safety. The H1N1 virus, which caused a world-wide pandemic earlier has now transformed into a seasonal flu virus. Aims: The aim of this study was to analyze the incidence of 2009-10 pandemic influenza A (H1N1) vaccination among Libyan HCPs in four hospitals of Al-Zawia, Libya. Materials and Methods: A questionnaire, which listed eight sections of parameters distributed among 310 HCPs to assess the vaccination rate and resulting adverse effects. Statistical Analysis: The data were analyzed using descriptive statistics, Pearson's χ2-test and Student's t-test where appropriate. Results: The overall pandemic A (H1N1) vaccination among all HCPs was only 107 (39.9%) out of 268 respondents. The distribution of respondents based on physicians, other staff and sex were found significant (P < 0.05). The common barriers of H1N1 vaccination being lack of awareness fear of adverse effects, allergies and religious beliefs. The major adverse effect observed was erythema in 95.56% of physicians and 87.1% in other staff. About 2% of HCPs have reported arthralgia. No significant differences existed between the responses of general variables and adverse effects. The glycoprotein 120 and squalene were found responsible for the reported adverse effects. 37 (82.22%) vaccinated medical HCPs have advised their patients to get vaccinated. Conclusions: Due to recurrence of H1N1 influenza in recent times, vaccination campaigns should be promoted immediately to address the knowledge gap of HCPs for intervention by regulatory and health organizations in Libya. The health belief model could be applied to improve vaccination among HCPs.
Keywords: Cross-sectional, health care personnel′s, H1N1, Libya, pandemic, retrospective study
|How to cite this article:|
Hwisa NT, Katakam P, Chandu BR, Ismael MH, Bader A. Pandemic influenza A (H1N1) vaccination among libyan health care personnel: A cross-sectional retrospective study. J Pharm Bioall Sci 2014;6:192-7
|How to cite this URL:|
Hwisa NT, Katakam P, Chandu BR, Ismael MH, Bader A. Pandemic influenza A (H1N1) vaccination among libyan health care personnel: A cross-sectional retrospective study. J Pharm Bioall Sci [serial online] 2014 [cited 2020 May 31];6:192-7. Available from: http://www.jpbsonline.org/text.asp?2014/6/3/192/130958
Influenza A (H1N1) virus is the subtype of influenza A virus that was the most common cause of human influenza (flu) in 2009. As of May 30, 2010 global update by the World Health Organization (WHO) over 214 countries have reported cases of pandemic influenza H1N1 2009, including more than 18,138 deaths.  On August 10, 2010, the WHO had declared that the H1N1 influenza pandemic was ended, stating that the flu activity had returned to typical seasonal patterns. However, small regional outbreaks or epidemics that comprise serious disease in younger age groups were expected to continue during the post-pandemic phase. , Recently, five deaths have been reported among the 29 suspected cases of influenza A (H1N1) virus infections in Libya during the month of March 2013. The H1N1 virus, which caused a worldwide pandemic in 2009 and 2010, has now transformed into a seasonal flu virus, a "hybrid" of a number of swine and avian flu viruses.  The WHO does not list Libya among the countries displaying the infection. However, it cautions "member states to continue surveillance for severe acute respiratory infections and to carefully review any unusual patterns".  WHO recommends member states to report on post-pandemic surveillance and are encouraged to use standard WHO case definitions for surveillance.  The main purpose of vaccination is to reduce morbidity, mortality and transmission of the virus within societies. Monovalent and trivalent vaccines are designed to protect against all three currently circulating influenza viruses. Annual vaccination is recommended by WHO for individuals because; (i) the period of protection is vague and may be shorter in high risk groups such as elderly and immune-compromised patients and (ii) vaccine protection is not assured from one season to the next due to antigenic drift of viruses. 
Health care personnel's (HCPs) are all those persons working in health care settings who have potential exposure to patients and infectious agents directly or indirectly. HCPs might include (but not limited to) all medical, paramedical, technical, administrative and housekeeping persons involved in patient care.  Notwithstanding improvements in clinical education, awareness and precautions, the rate of vaccination for HCPs is at undesirable levels for the past three decades. This is in turn adversely influencing patient safety. It is the moral, ethical and legal responsibility of health care institutions to change the existing status of vaccination of HCP by making influenza vaccination a mandatory solution. Scientific analysis and deployment of the data helps in identifying the actual situation of vaccination to HCP at regional and country levels and thereby helping the regulatory authorities to opt for a proper solution. The recent influenza pandemic offers an opportunity for policy makers to reconsider the benefits of compulsory influenza vaccination for HCPs, ensuring patient safety and strengthening the health care system. 
In a study among health personnel, it was found that the willingness to accept pre-pandemic influenza vaccination was low and no significant effect was observed with the change in the WHO alert level.  A similar result was obtained in other population-based surveys in influenza vaccination of HCPs.  Misinformation regarding hospital policies and unawareness were other reasons for poor vaccination among HCPs.  In another study, it was found that there was an increase of 25% in vaccination and therefore it appears that more active campaigns might increase influenza vaccination among HCPs.  A sustained management attention can lead to improvements in health care worker influenza vaccination rates. 
The Centers for Disease Control and Prevention (CDC) has recommended vaccination of health care workers against influenza since 1981.  Recent studies revealed that influenza vaccination to health care workers has reduced the resident mortality to 44%.  It has been predicted from a study that, if all the HCPs were vaccinated, then about 60% of patient influenza infections could be prevented.  Influenza vaccination of health care workers reduces employee illness and absenteeism.  The National Patient Safety Foundation, the American Medical Association, CDC, The Society for Health care Epidemiology, the Association for Professionals in Infection Control and the Infectious Disease Society of America also strongly supported for mandatory influenza vaccination in view of patient safety. In a recent study it was found that the mandatory vaccination program successfully increased vaccination rates among HCPs at a large multihospital health care organization. ,,, To the best of our knowledge no study has been reported on any vaccination of HCPs in Libya. Such studies are very important to this country and to WHO such that future vaccination programs could be more effective.
The aim of this study was to analyze the incidence of pandemic influenza A (H1N1) vaccination among Libyan HCPs. For this, a cross-sectional retrospective study was performed for the 2009-10 pandemic influenza vaccination among HCPs at four tertiary care hospitals of Al-Zawia, Libya. This study also focused to obtain information about the benefits, adverse effects, toxicity and risks associated with the pandemic influenza A (H1N1) vaccination among HCPs. The study was expected to provide necessary inputs to the regulatory authorities and commercial organizations for future decisions on vaccination formulations and regulations.
| Materials and Methods|| |
A cross-sectional retrospective A (H1N1) vaccination among Libyan HCPs was conducted in four tertiary care hospitals namely; University Medical Hospital, Regional Tuberculosis Center, Mozamma Government Poly Clinic and Di-El-Hilal Poly Clinic of Al-Zawia, Libya. The data collection form was prepared by three pharmacy academicians, approved by the institutional committee on clinical studies (approval reference number, FP/IEC/2011-12/02) and distributed to hospitals for the survey. A total of 310 questionnaires were distributed to the medical staff of hospitals, to obtain the H1N1 utilization data from physicians, surgeons, nurses, technicians, pharmacists and cleaning personnel. The hospital authorities were contacted through request letters to obtain approval to send the anonymous questionnaires to their staff. The questionnaire consisted of eight sections to collect data on: (1) personal demographics; (2) acceptance of pandemic vaccination with H1N1 vaccine; (3) reasoning for vaccination; (4) whether vaccination is by voluntary or as a mandatory force; (5) concerns about H1N1 vaccination; (6) adverse effects precipitated after vaccination; (7) whether H1N1 vaccine was effective in the prophylaxis against swine flu; and (8) whether advise their patients regarding H1N1 vaccination. The participants were requested to submit the questionnaire in a sealed cover. The data from 268 HCPs for the pandemic period of 2009-10 was collected and recorded on the questionnaire during the month of April 2011. The obtained data from respondents was pooled into two categories: Physicians (including physicians, surgeons and specialists as per North American classification) and other staff (nurses, pharmacists, technicians and cleaning personnel).
The data were fed into Microsoft Excel software (Microsoft Office 2007, Microsoft Corporation, Redmond, USA) for analysis and descriptive statistics. Using cross tabulations, we analyzed univariate associations between intention to accept vaccine and the following variables: Sex, physicians and other staff along with demographics and adverse effects. The statistical significance of the associations was tested using Pearson's χ2 test and Student's t-test where appropriate. A flexible modeling approach was adopted and variables were retained in the model if they had P < 0.05.
| Results|| |
A cross-sectional pandemic A (H1N1) vaccine utilization study was conducted among physicians and other staff with the help of a questionnaire in four tertiary care hospitals in Al-Zawia during the month of April 2011. Of the 310 questionnaires distributed in the survey, 268 were completed and returned from the HCPs giving a response rate of 86.45%. Comparing the actual response to the questionnaire, the distribution of respondents based on physicians, other staff and sex were found significant (P < 0.05), whereas those based on a total percentage of physicians and other staff; and total males and females, the distribution was found non-significant.
The demographics of the questionnaire respondents are shown in [Table 1]. The overall pandemic A (H1N1) vaccination among all HCPs was only 107 (39.9%) out of 268 respondents.
|Table 1: Demographic characteristics of the respondents to the questionnaire|
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All vaccinated HCPs stated that, they should be protected and they followed the hospital authorities' advice during vaccination period. The reasons claimed by HCPs who refused vaccination were: Allergy, lack of awareness, fear of adverse effects, religious beliefs and sometimes no reason. The variability of distribution of reasons for avoiding vaccination between physicians and other staff was found non-significant. The results are summarized in [Table 2] and [Figure 1]. The vaccination rate did not vary between physicians and other staff.
|Table 2: Reasons for no vaccination during the pandemic influenza vaccination in the survey of physicians and other staff|
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|Figure 1: Response of healthcare personnel not availing pandemic influenza vaccination|
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A univariate association of variables affecting the pandemic influenza vaccination in the survey of physicians and other staff is shown in [Table 3] and [Table 4]. There were no significant differences existed between the responses of general variables and adverse effects associated with vaccination. A similar trend was observed for both physicians and other staff. 37 (82.22%) vaccinated physicians have advised their patients to avail vaccination. Compared to physicians more percentage of the other staff was vaccinated. The reason being that they were likely to get attracted by the influenza and that a pandemic would seriously affect their lives. The response comparison of various parameters among physicians and other staff are depicted in [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Table 3: Univariate association of variables affecting the pandemic influenza vaccination in the survey of physicians (total 112)|
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|Table 4: Univariate association of variables affecting the pandemic influenza vaccination in the survey of other staff (total 156)|
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|Figure 2: Response of physicians to basic aspects of pandemic influenza vaccination|
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|Figure 3: Response of physicians on adverse effects faced after vaccination|
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|Figure 4: Response of other staff to basic aspects of pandemic influenza vaccination|
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|Figure 5: Response of other staff on adverse effects faced after vaccination|
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| Discussion|| |
The present study was triggered by the recent deaths occurred in Libya due to the H1N1 virus. This alarms the present situation in Libya on H1N1 influenza infection. Our retrospective survey found a low level of willingness to accept pandemic influenza vaccination among hospital based HCPs. Although there is a lack of sophisticated and well organized health care system in Libya, due to high alert levels by WHO during 2009-10 outbreak of SARS virus, the government has provided all the necessary inputs for ensuring vaccination to all the public including HCPs. However the acceptance levels of H1N1 influenza (swine flu) vaccine in our survey was less than 40%. As for September, 2009 Libya has 233 laboratory confirmed cases and one death due to swine flu virus during the initiation of vaccination period. The WHO also recommended that all countries should immunize their health care workers immediately to protect the essential health infrastructure.  A low level of acceptance of vaccination warrants the attention of HCPs.
Barriers of vaccination
The common barriers of H1N1 vaccination being lack of awareness, fear of adverse effects, allergies and religious beliefs influenced the HCPs in Al-Zawia. Efforts to improve the uptake of seasonal influenza vaccination by health care workers should therefore be a part of the pandemic preparedness plan.
Expected reasons for adverse effects
The respondents allergic to chicken egg were more prone to adverse effects such as hyperthermia and erythema due to antigenic activity. The commonly used adjuvants in commercial H1N1 vaccines were squalene, thiomersal and a glycoprotein (gp120). Squalene is approved by European countries as an adjuvant to help stimulate the immune response through the production of CD4 memory cells. However, the US FDA has not authorized this as adjuvant. Glaxo Smith Kline (GSK, UK) used the squalene-based AS03 adjuvant in their 2009 influenza pandemic vaccines. Later, Pandemrix® and Arepanrix® were withdrawn from the market due to their adverse effects. , The a gp120 was mixed with squalene to have a synergistic effect on the antigenic property of vaccines lasting over a year.  Thiomersal is a commonly used vaccine preservative which is present only in multi-dose vials. Due to its toxicity, single-dose syringes are recommended for pregnant women and small children.  In our study, all the HCPs received the vaccine from multi-dose vials. The vaccine that the physicians contracted was Aggripal® produced by Novartis which contained both squalene and thiomerosal. Triggering of arthritis in the reported cases could be due to the presence of squalene. Presently the vaccines are produced without these additives.
Strengths and weaknesses of this study
To the best of our knowledge, this is the first study conducted in Libya to assess the health care workers on the acceptance of pandemic influenza vaccination. This study provides important information on status and barriers of vaccination in Libyan community. Campaigns to promote vaccination should be done immediately to address the knowledge gap of HCPs for intervention by regulatory and health organizations of Libya. The main limitation of this study was the small sample size (268) and response rate of below 40% which might have resulted in a biased sample. The low sample size was due to the less population size of the city of Al-Zawia and less well organized health care sector. However the sample size was enough to represent the situation of pandemic vaccination of HCPs in Al-Zawia.
Due to recurrence of H1N1 influenza in recent times, efforts should be made to improve the uptake of seasonal influenza vaccination by health care workers as a part of the pandemic preparedness plan. The health belief model could be applied to improve the acceptance of pandemic vaccine as in the case of seasonal influenza vaccination. 
The public and health care organizations need to provide more information to the staff, especially to those with higher levels of anxiety and doubts. The vaccines should be available at low or no cost to the HCPs. Cultural and religious obstacles to vaccination should be overcome by proper education through mass media. ,
| Conclusions|| |
The present investigation has resulted in a document which reflects the actual pandemic A (H1N1) vaccination among HCPs in four tertiary care hospitals of Al-Zawia, Libya. Similar studies should be conducted in various cities of Libya to verify the present sample results and compile a large database for authentication. Further extensions of the studies such as group discussions could help to consolidate and supplement the findings.
| Acknowledgment|| |
The authors would like to acknowledge all the managements of the four hospitals and Faculty of Pharmacy, Al-Zawia, Libya for making this study a success.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]