To the best of our knowledge, this study is the first in Lebanon to evaluate the influenza uptake rate among hospital-based HCWs in the context of COVID-19 and to determine factors associated with the willingness to vaccinate by exploring knowledge, attitudes, perceived barriers, benefits, and practices among this population. The study’s main findings are that almost all surveyed HCWs have a sufficient knowledge level with nearly half of them had a good knowledge level (≥80%). These results are consistent with the findings displayed in a study conducted in the United States reporting a knowledge level ≥80% among nurses . Besides, less than 1% of HCWs exhibited a poor overall knowledge score. The gaps in knowledge were more ostensible and concrete in the knowledge domain related to the prioritization of the target groups when a limited supply of vaccine is experienced. A peculiar finding in this study was that more than half of surveyed HCWs considered that pregnant women are not among prioritized groups for influenza vaccination. Lack of consciousness among HCWs about the importance of influenza vaccination among pregnant women could lead them to skip advising pregnant women about the essentiality of influenza vaccine during pregnancy. Many studies reflected that lack of knowledge among health care providers (HCP) could impact negatively the pregnant women uptake of influenza vaccine since their decision was based basically on compelling advice provided by HCWs [23-25].
Moreover, 60% of surveyed HCWs didn’t believe that children aged between 6 months and 5 years are among the prioritized target groups for influenza vaccination. Many studies shed light on the importance of prioritizing influenza vaccination of children to minimize infection in the community and because they had the longest lives ahead of them [14, 26, 27].
Another important finding in this study was that nearly half of HCWs were not aware about the incubation period of the influenza virus and 23.8% of them didn’t recognize the timeframe of influenza vaccination and the fact the vaccine can continue to be offered as long as influenza viruses are circulating (timeframe). Such deficiency in knowledge concerning target groups and timing of vaccination could lead to the falloff of the vaccination coverage among HCWs and the Lebanese population. These gaps in knowledge underline the importance of raising awareness among HCWs regarding influenza target groups and vaccination timeframe.
The majority of HCWs considered influenza as a serious disease and they support that vaccination against influenza should be mandatory. A study conducted in Saudi Arabia exhibited that recommendations from the government on influenza vaccination for HCWs and compulsory requirements were significant determinants of vaccine acceptance .
Almost half of them disclosed that even healthy people do need to vaccinate and that benefits of evading the disease are pertinent. However, a critical review conducted by Abramson showed that the personal benefit from vaccinating healthy nonelderly adults is small . Besides, the majority of HCWs disagreed about the ability of vaccines to weaken or overload the immune system. They disapproved that influenza vaccination is leading to the rise of allergies as well. To date, utmost studies disclosed strong evidence that no association between influenza vaccines and increased risk for atopy, asthma symptoms, exacerbations, or increased use of rescue medications [30, 31].
However, 28.8% of them thought that developing natural immunity is better than getting the vaccine. Despite the fact, that a flu infection would stimulate the immune system more strongly than the vaccine will, but that comes with a substantial price in case that the person got sick and developed complications and might die. In addition, the immunity gained from a bout of influenza only protects against a particular subtype but that’s just one of the four lineages, and it drifts and won’t last long because of those rapid mutations of the influenza virus . Besides, more than one-third of HCWs thought that adverse reactions resulting from influenza vaccination were underestimated. These results are consistent with the findings of a study conducted in Germany where physicians and non-vaccinated nurses overestimated the rates of both non-severe and severe adverse effects. This was negatively associated to vaccination rates among all professionals .
Concerning their attitudes towards the Lebanese government, more than half of HCWs declared that the Lebanese society has more vital challenges and trials further than influenza. This could be due to the heavy economic crisis, accompanied by a dangerous depletion of resources, including human capital aggravated by the COVID-19 pandemic and the Beirut blast.
The majority of HCWs also considered that influenza vaccine would be provided for free and should be financed by the government and more than 40% of them thought that the health facility where they work should ensure the availability of influenza vaccine at their institution. In some neighboring countries, influenza vaccines are offered free of charge for all the population . Despite that influenza vaccine is not considered costly, but, ensuring its availability at the health facility and providing it for free could increase vaccination coverage among health care workers
In addition, some HCWs appraised that vaccine policy in Lebanon is influenced by the financial profits of pharmaceutical companies. This could be well understood given the Lebanese loss of trust toward the political system. Despite this fact, nearly half of HCWs ponder that information provided by health authorities is reliable.
Another noteworthy finding in the study is that 83.3% of the HCWs listed the availability of a sufficient quantity of vaccine for the current year at the top of challenges that will hinder their access to vaccines. The conceivable shortage faced will be due to the high demand during the current year. The panic generated by the COVID-19 pandemic and the fear of getting co-infected has prompted people to seek influenza vaccination, in order to prevent COVID-19 complications and reduce the burden on the healthcare system.
In addition, the development of side effects (23.57%), severe adverse events (31.07%), and vaccine safety (18.21%) were listed between impediments of vaccination. Since the cost of the vaccine is paid out-of-the-pocket in Lebanon, the cost of the vaccine was stated as a barrier. Similar impediments of vaccination were revealed in different studies conducted in Singapore and Saudi Arabia [35-37].
The main benefits mentioned by HCWs’ uptake or willingness to be vaccinated include enhancing patient safety, minimizing the viral reservoir in the population, decreasing hospital admission due to influenza, and avoiding co-infection by influenza and COVID-19 allowing consequently health services to better cope with COVID-19 complications. Whereas, only 39.29% of HCWs ponder influenza vaccination as a cost-effective intervention. Our results are consistent with the benefits reported in many studies. A systematic review of randomized trials showed that HCWs’ influenza vaccination can enhance patient safety [9, 38, 39].
Despite the annual recommendation of influenza vaccination issued by the ministry of public health, the findings of our study showed that only 32.1% of the surveyed HCWs received their influenza vaccine in the past season (2019-2020). This vaccination coverage rate is considered low compared to the neighboring countries. A recent review reported that the lowest rate of HCWs’ vaccination against influenza was recorded in Vietnam (3.7%) and the highest one was accorded to Japan (85.7%) . For the season 2016-2017, Qatar reached a vaccination coverage rate of 77% among HCWs . Similarly, almost 67.6% of HCWs were vaccinated in the 2016 season in Saudi Arabia . Indeed, a higher influenza vaccination rate could be attributed to the fact that these countries have ensured the availability of free of charge vaccines and conduct vaccination campaigns.
One noteworthy finding in the present study is that uptake of influenza vaccine during this season (2020-2021) which overlaps with the circulation of SARS-Cov2, rise to 80.2% among HCWs. Given that medical professionals stressed the importance of the influenza vaccine during the COVID-19 pandemic, the willingness to vaccinate against influenza in the current year seemed to be highly affected by the COVID-19 pandemic. In addition, receiving the influenza vaccine in the past season is highly associated with the willingness to vaccinate during the current season. Similar results were found by a study conducted in Germany where receiving the influenza vaccination in the previous season was the strongest independent predictor of pandemic influenza vaccination . These findings also were reflected in many systematic reviews that have repeatedly recognized past behavior as a strong predictor of influenza vaccine acceptance [43, 44].
Regarding marital status, we found that being separated or divorced decreased the vaccination uptake. This result is consistent with the findings of the study that found that being widowed increased the decision to become immunized while being separated or divorced decreased it . Despite some authors found no relationship between those variables, marital status is considered an important predictor of healthcare utilization. In fact, marriage may influence health status not only through the support and protection that marriage offers but also through a more efficient pattern of healthcare utilization .
In this study, the large experience of HCWs was not linked to the intention to receive vaccine despite that other studies have associated large experience to high willingness and acceptance rate. Similar findings were observed in a study conducted in Oman where experience did not correlate with greater compliance with vaccination . In addition, HCWs who rated their health status as fair or below were more likely to get influenza vaccination compared to other HCWs who had a good health status. Similar findings were reported in a study conducted among Italian HCWs .
On the contrary, the professional occupation was not associated with vaccine uptake. No significant difference was shown between physicians, nurses, laboratory technicians, and pharmacists. However, a study conducted in Dubai disclosed an association between the professional occupation of HCWs and vaccines with the highest uptake among physicians followed by nurses. Less perception of barriers and positive perception of benefits were associated with a high willingness to vaccinate. Our results disclosed also that a good knowledge score was associated with the willingness to be immunized against influenza. Participants with good knowledge of the safety of vaccines were more conceivable to get the vaccine. These findings were in line with the results displayed in a study conducted in Dubai where the proportion of HCWs with good knowledge had a higher level of acceptance of vaccine .
The adoption of positive behaviors such as encouraging patients, relatives, and colleagues to get vaccinated against influenza, attending training related to vaccination, and addressing influenza vaccine hesitancy was reported among HCWs. Many studies highlighted the importance of positive behavior in improving the vaccination coverage rate.