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Preplanned Studies: Attitudes Regarding Influenza Vaccination Among Public Health Workers during COVID-19 Pandemic — China, September 2022

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  • Summary

    What is already known about this topic?

    Public health workers (PHWs) were listed as a priority group recommended for influenza vaccination during the coronavirus disease 2019 (COVID-19) pandemic. Understanding the drivers of influenza vaccine hesitancy among PHWs can promote influenza vaccination in the COVID-19 pandemic.

    What is added by this report?

    The study found that 10.7% of PHWs were hesitant to get an influenza vaccination. Drivers associated with vaccine hesitancy were assessed based on “3Cs model.” The absence of a government or workplace requirement and concerns about vaccine safety were the biggest obstacles for PHWs to recommend influenza vaccination.

    What are the implications for public health practice?

    Interventions are needed to improve PHWs’ influenza vaccine coverage to prevent the co-circulation of influenza and COVID-19.

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  • Funding: Supported by the China Association for Science and Technology (Project Number: 2021ZZKCB082026), and Bill & Melinda Gates Foundation (Project Number: INV-023808)
  • [1] Lafond KE, Porter RM, Whaley MJ, Zhou SZ, Zhang R, Aleem MA, et al. Global burden of influenza-associated lower respiratory tract infections and hospitalizations among adults: A systematic review and meta-analysis. PLoS Med 2021;18(3):e1003550. http://dx.doi.org/10.1371/journal.pmed.1003550CrossRef
    [2] World Health Organization. Recommended composition of influenza virus vaccines for use in the 2023 southern hemisphere influenza season. 2022. https://cdn.who.int/media/docs/default-source/influenza/who-influenza-recommendations/vcm-southern-hemisphere-recommendation-2023/202209_recommendation.pdf?sfvrsn=83a26d50_3&download=true. [2022-11-10].https://cdn.who.int/media/docs/default-source/influenza/who-influenza-recommendations/vcm-southern-hemisphere-recommendation-2023/202209_recommendation.pdf?sfvrsn=83a26d50_3&download=true
    [3] Imai C, Toizumi M, Hall L, Lambert S, Halton K, Merollini K. A systematic review and meta-analysis of the direct epidemiological and economic effects of seasonal influenza vaccination on healthcare workers. PLoS One 2018;13(6):e0198685. http://dx.doi.org/10.1371/journal.pone.0198685CrossRef
    [4] Ma LB, Han X, Ma Y, Yang Y, Xu YS, Liu D, et al. Decreased influenza vaccination coverage among Chinese healthcare workers during the COVID-19 pandemic. Infect Dis Poverty 2022;11(1):105. http://dx.doi.org/10.1186/S40249-022-01029-0CrossRef
    [5] Liu HT, Tan YY, Zhang ML, Peng ZB, Zheng JD, Qin Y, et al. An internet-based survey of influenza vaccination coverage in healthcare workers in China, 2018/2019 season. Vaccines 2020;8(1):6. http://dx.doi.org/10.3390/vaccines8010006CrossRef
    [6] Three-Generation Technology, Shenzhen. Brief introduction of listening to the experts platform. http://www.threegene.com/html/1/2/34/index.html. [2022-10-20]. (In Chinese). http://www.threegene.com/html/1/2/34/index.html
    [7] National Bureau of Statistics of China. National data. https://data.stats.gov.cn/easyquery.htm?cn=E0103. [2022-10-20]. (In Chinese). https://data.stats.gov.cn/easyquery.htm?cn=E0103
    [8] MacDonald NE, The SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015;33(34):4161 − 4. http://dx.doi.org/10.1016/j.vaccine.2015.04.036CrossRef
    [9] Zhang XX, Wang W, Zhang ZN, Song YF, Yu WZ. Willingness of vaccination staff to recommend non-expanded program on immunization vaccines and factors influencing willingness: a cross-sectional survey. Chin J Vaccines Immun 2022;28(3):329 − 33. http://dx.doi.org/10.19914/j.CJVI.2022063 (In Chinese). CrossRef
    [10] Swets MC, Russell CD, Harrison EM, Docherty AB, Lone N, Girvan M, et al. SARS-CoV-2 co-infection with influenza viruses, respiratory syncytial virus, or adenoviruses. Lancet 2022;399(10334):1463 − 4. http://dx.doi.org/10.1016/S0140-6736(22)00383-XCrossRef
  • TABLE 1.  Reasons for influenza vaccine hesitancy among PHWs (Based on 3Cs model) in China, September 2022.

    VariableVery unacceptable (%)Unacceptable (%)Acceptable (%)Highly acceptable (%)
    Convenience
    High prices37.821.127.413.7
    Don’t know when to vaccinate66.112.814.07.1
    No appropriate to take influenza vaccination56.824.412.26.5
    Vaccination place is inconvenient69.312.89.58.3
    Spend long time waiting for taking influenza vaccination62.520.511.35.7
    Don't know where to vaccinate73.211.68.96.3
    Influenza vaccination services are hard to make appointment67.917.69.84.8
    Confidence
    Being worried about adverse reactions50.321.421.76.5
    No influenza vaccination notification at workplace56.016.414.313.4
    Influenza vaccine is not effective49.425.020.25.4
    Having contraindications56.019.616.18.3
    Pregnant or lactating67.014.610.18.3
    Complacency
    Influenza will not cause severe illness31.325.332.111.3
    Abbreviation: PHWs=public health workers.
    Download: CSV

    TABLE 2.  Reasons for influenza vaccine recommendation among PHWs in China, September 2022.

    VariableTotal (n, %)Willing to recommend (n, %)
    Worried about the misunderstanding of commercial interests by recipients1,440 (46.1)1,387 (47.1)
    Worried about the adverse reactions of recipients1,313 (42.0)1,252 (42.5)
    No recommendation on requirement by national authorities or at workplace1,312 (42.0)1,233 (41.9)
    Pregnancy or have contraindications1,123 (35.9)1,068 (36.3)
    Influenza won't cause severe illness and vaccination is unnecessary1,065 (34.1)1,004 (34.1)
    Worried about the medical tangle caused by recommendation927 (29.6)886 (30.1)
    Influenza vaccine is not effective861 (27.5)819 (27.8)
    Due to self-unvaccinated and lack of influenza vaccine confidence596 (19.1)551 (18.7)
    Influenza vaccination is inconvenient354 (11.3)336 (11.4)
    Abbreviation: PHWs=public health workers.
    Download: CSV

    TABLE 3.  Univariate analysis and multivariable logistic regression analysis of influenza vaccine hesitancy among public health workers in China, September 2022 (ref: willing to vaccination).

    VariableTotal (n, %)Vaccination willingness (n, %)Vaccine hesitancy
    (n, %)
    Univariate analysisLogistic regression analysis
    χ2P for chi-square testOR (95% CI)P-value
    PLAD by GDP per capita*
    Low GDP area680 (21.7)588 (86.5)92 (13.5)8.810.012Ref
    Middle GDP area1,413 (45.2)1,262 (89.3)151 (10.7)0.85 (0.61–1.19)0.346
    High GDP area1,034 (33.1)941 (91.0)93 (9.0)0.61 (0.43–0.88)0.008
    Type of workplace
    Community health service centers/Township health centers2,304 (73.7)2,043 (88.7)261 (11.3)3.100.078Ref
    Center for Disease Control and Prevention823 (26.3)748 (90.9)75 (9.1)0.86 (0.60–1.22)0.392
    Professional title
    None347 (11.1)296 (85.3)51 (14.7)8.880.031Ref
    Junior1,206 (38.6)1,070 (88.7)136 (11.3)1.21 (0.78–1.86)0.397
    Middle1,212 (38.8)1,095 (90.3)117 (9.7)1.19 (0.76–1.87)0.446
    Senior362 (11.6)330 (91.2)32 (8.8)1.25 (0.70–2.23)0.458
    Chronic diseases history (Except for simple hypertension)
    Yes153 (4.9)133 (86.9)20 (13.1)3.370.185Ref
    No2,922 (93.4)2,615 (89.5)307 (10.5)0.51 (0.28–0.94)0.030
    Unclear52 (1.7)43 (82.7)9 (17.3)0.72 (0.26–2.03)0.538
    Influenza infection history since September 2021
    Yes424 (13.6)400 (94.3)24 (5.7)13.260.001Ref
    No2,176 (69.6)1,926 (88.5)250 (11.5)1.98 (1.21–3.24)0.006
    Unclear527 (16.9)465 (88.2)62 (11.8)1.98 (1.14–3.42)0.015
    Received influenza vaccine between September 2021 and April 2022
    Yes1,643 (52.5)1,600 (97.4)43 (2.6)238.48<0.001Ref<0.001
    No1,484 (47.5)1,191 (80.3)293 (19.7)5.08 (3.54–7.29)
    On-site vaccination at workplace
    Yes2,650 (84.7)2,400 (90.6)250 (9.4)31.60<0.001Ref
    No403 (12.9)332 (82.4)71 (17.6)1.50 (1.03–2.20)0.037
    Unclear74 (2.4)59 (79.7)15 (20.3)1.47 (0.71–3.07)0.303
    Ways of influenza vaccine payment
    Self-paid2,333 (74.6)2,047 (87.7)286 (12.3)43.49<0.001Ref
    Free329 (10.5)313 (95.1)16 (4.9)0.60 (0.31–1.17)0.132
    Employer paid225 (7.2)214 (95.1)11 (4.9)0.89 (0.43–1.87)0.763
    Medical insurance208 (6.7)188 (90.4)20 (9.6)0.63 (0.36–1.11)0.111
    Unclear32 (1.0)29 (90.6)3 (9.4)0.39 (0.10–1.58)0.185
    Convenience of payment method
    Very convenient973 (31.1)910 (93.5)63 (6.5)43.49<0.001Ref
    Moderately convenient1,295 (41.4)1,157 (89.3)138 (10.7)0.95 (0.66–1.39)0.807
    A little convenient558 (17.8)463 (83.0)95 (17.0)1.32 (0.86–2.01)0.202
    Not at all convenient301 (9.6)261 (86.7)40 (13.3)1.10 (0.65–1.86)0.717
    Perceived risk of influenza this season
    Very concerned132 (4.2)130 (98.5)2 (1.5)41.06<0.001Ref
    Moderately concerned243 (7.8)230 (94.7)13 (5.3)2.53 (0.48–13.47)0.276
    A little concerned1,590 (50.8)1,440 (90.6)150 (9.4)3.11 (0.64–15.04)0.158
    Not at all concerned1,162 (37.2)991 (85.3)171 (14.7)5.26 (1.09–25.41)0.039
    Health influence of the influenza vaccine
    Very important1,531 (49.0)1,482 (96.8)49 (3.2)396.93<0.001Ref
    Moderately important1,055 (33.7)932 (88.3)123 (11.7)2.50 (1.71–3.64)<0.001
    A little important480 (15.4)356 (74.2)124 (25.8)4.21 (2.81–6.30)<0.001
    Not at all important61 (2.0)21 (34.4)40 (65.6)21.32 (10.15–44.80)<0.001
    Whether the trivalent or quadrivalent influenza vaccine affects willingness
    No1,137 (36.4)975 (85.8)162 (14.2)22.86<0.001Ref
    Yes1,990 (63.6)1,816 (91.3)174 (8.7)0.97 (0.72–1.31)0.836
    Whether the inactivated or live-attenuated vaccine influences willingness
    No1,325 (42.4)1,139 (86.0)186 (14.0)25.99<0.001Ref
    Yes1,802 (57.6)1,652 (91.7)150 (8.3)0.66 (0.49–0.89)0.006
    Workplace vaccination policy (free for all staff)
    Yes810 (25.9)766 (94.6)44 (5.4)34.16<0.001Ref
    No2,038 (65.2)1,788 (87.7)250 (12.3)0.88 (0.55–1.41)0.602
    Unclear279 (8.9)237 (84.9)42 (15.1)0.70 (0.39–1.28)0.248
    Expectation from colleagues toward influenza vaccination this season
    No65 (2.1)44 (67.7)21 (32.3)213.15<0.001Ref
    Yes1,715 (54.8)1,653 (96.4)62 (3.6)0.18 (0.09–0.37)<0.001
    Unclear1,347 (43.1)1,094 (81.2)253 (18.8)0.58 (0.28–1.19)0.135
    Attitudes toward influenza vaccine this season at your workplace
    Required343 (11.0)328 (95.6)15 (4.4)94.5<0.001Ref
    Encouraged1,038 (33.2)978 (94.2)60 (5.8)1.15 (0.59–2.25)0.678
    Neutrality1,442 (46.1)1,249 (86.6)193 (13.4)1.42 (0.73–2.74)0.301
    Unclear304 (9.7)236 (77.6)68 (22.4)1.57 (0.76–3.23)0.219
    How extensive do you consider your knowledge of the influenza vaccine
    Very confident1,361 (43.5)1,280 (94.0)81 (6.0)88.5<0.001Ref
    Moderately confident1,181 (37.8)1,044 (88.4)137 (11.6)1.22 (0.87–1.72)0.252
    A little confident447 (14.3)354 (79.2)93 (20.8)1.45 (0.98–2.16)0.065
    Not at all confident138 (4.4)113 (81.9)25 (18.1)  1.66 (0.91–3.03)0.101
    Abbreviations: OR=adds ratio; CI=confidence interval.
    * In terms of GDP per capita, provincial-level administrative divisions (PLADs) are divided into three levels: low, middle and high.
    Low for Anhui, Qinghai, Jiangxi, Shanxi, Heilongjiang, Guangxi, Guizhou,Yunnan, Gansu;
    Middle for Chongqing, Shaanxi, Liaoning, Jilin, Hunan, Hainan, Henan, Sichuan, Hebei;
    High for Beijing, Shanghai, Tianjin, Jiangsu, Zhejiang, Fujian, Guangdong, Shandong, Inner Mongolia, Hubei.
    Download: CSV

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Attitudes Regarding Influenza Vaccination Among Public Health Workers during COVID-19 Pandemic — China, September 2022

View author affiliations

Summary

What is already known about this topic?

Public health workers (PHWs) were listed as a priority group recommended for influenza vaccination during the coronavirus disease 2019 (COVID-19) pandemic. Understanding the drivers of influenza vaccine hesitancy among PHWs can promote influenza vaccination in the COVID-19 pandemic.

What is added by this report?

The study found that 10.7% of PHWs were hesitant to get an influenza vaccination. Drivers associated with vaccine hesitancy were assessed based on “3Cs model.” The absence of a government or workplace requirement and concerns about vaccine safety were the biggest obstacles for PHWs to recommend influenza vaccination.

What are the implications for public health practice?

Interventions are needed to improve PHWs’ influenza vaccine coverage to prevent the co-circulation of influenza and COVID-19.

  • 1. Chinese Preventive Medicine Association, Beijing, China
  • 2. Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
  • 3. Division of Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding authors:

    Jiandong Zheng, zhengjd@chinacdc.cn

    Luzhao Feng, fengluzhao@cams.cn

  • Funding: Supported by the China Association for Science and Technology (Project Number: 2021ZZKCB082026), and Bill & Melinda Gates Foundation (Project Number: INV-023808)
  • Online Date: February 10 2023
    Issue Date: February 10 2023
    doi: 10.46234/ccdcw2023.025
  • Globally, influenza causes 3–5 million hospitalizations and 290,000–650,000 respiratory deaths each year (1). From February through August 2022, influenza activity was at its highest level compared to similar periods since the start of the coronavirus disease 2019 (COVID-19) pandemic globally (2). As the priority group recommended for influenza vaccination during the COVID-19 pandemic, healthcare workers (HCWs), including public health workers (PHWs), have a greater chance of contracting influenza viruses; this poses a greater risk of transmission (3). PHWs refer to those who are engaged in public health services and vaccination work in the Center for Disease Control and Prevention (CDC) system, community health service centers, or township health centers. Previous surveys have shown that willingness and influence factors of front-line staff involved in the work of influenza control are of higher concern (4-5). The research mainly focused on assessing PHWs’ attitudes toward influenza vaccination in 2022–2023. Univariate analysis and multivariable logistic regression analysis were used to evaluate factors associated with vaccine hesitancy. A total of 3,127 PHWs were surveyed. 10.7% were hesitant about influenza vaccination in the coming season. Multivariate logistic regression analysis found that PHWs who did not receive an influenza vaccine between September 2021 and April 2022 [odds ratio (OR)=5.08, 95% confidence interval (CI): 3.54–7.29] and PHWs who believed vaccination had no importance for health (OR=21.32, 95% CI: 10.15–44.80) were more likely to hesitate to get vaccinated. The results suggest that effective measures should be taken to strengthen the willingness of PHWs to vaccinate against influenza. This reduces the burden of the COVID-19 responding and medical facilities.

    From September 16 to 26, 2022, a link to the questionnaire for the survey was posted on Listening to the Experts, a learning and communication platform that authenticates real identity information of registered users and was used by professionals in the field of vaccination in China (6). PHWs could voluntarily participate in the survey and forward it to their colleagues, but each participant could only answer once. As of September 30, 2022, the Listening to the Experts platform has over 650,000 PHW users, covering 31 provincial-level administrative divisions (PLADs) in China. Data on respondents’ sociodemographic characteristics, workplace interventions, knowledge of influenza vaccination, influenza vaccination history and attitudes towards recommending influenza vaccination were collected. The per capita gross domestic product (GDP) of each PLAD was obtained from the National Bureau of Statistics of China (7). Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. According to the “3Cs model” of vaccine hesitancy (8), the impact of confidence, complacency, and convenience on hesitancy to receive influenza vaccination was analyzed and concerns of PHWs in recommending influenza vaccination were presented. The study protocol and questionnaire were approved by the Chinese Academy of Medical Sciences and Peking Union Medical College (No. CAMS&PUMC-IEC-2022-019, on March 14, 2022).

    Univariate analysis included frequency and ratio calculations and Pearson’s chi-squared test for differences. Multivariate logistic regression was used to evaluate factors associated with intention to accept vaccination. ORs and 95% CIs were calculated. Alpha level was set at 0.05. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS, version 26.0, SPSS Inc, Chicago, IL, USA.).

    A total of 3,145 PHWs from 28 PLADs participated in the survey, with 18 incomplete questionnaires excluded. Among the 3,127 respondents in China, 823 (26.3%) work at CDC systems, and 2,304 (73.7%) were from community or township health service centers. Nearly half had an intermediate professional title or above and 10.7% (336) had influenza vaccine hesitancy. In the 2021–2022 influenza season, 52.5% respondents (1,643/3,127) were vaccinated against influenza, including 64.9% (1,067/1,643) vaccinated at a community or township health service center, 21.4% (352/1,643) vaccinated at a hospital, 12% (197/1,643) vaccinated at a CDC vaccination clinic, and 1.6% (27/1,643) vaccinated elsewhere.

    Of the 336 respondents with vaccine hesitancy, 22.3% (75/336) worked at CDC systems and 77.7% (261/336) worked at community or township health service centers. The analysis results based on the “3Cs model” illustrated that 43.45% of the respondents believed complacency, 24.88% believed confidence, and 20.79% believed convenience had an impact on vaccine hesitancy. In terms of complacency, 43.3% (146/336) believed that influenza infection would not cause serious illness and it did not matter if they were not vaccinated (Table 1).

    VariableVery unacceptable (%)Unacceptable (%)Acceptable (%)Highly acceptable (%)
    Convenience
    High prices37.821.127.413.7
    Don’t know when to vaccinate66.112.814.07.1
    No appropriate to take influenza vaccination56.824.412.26.5
    Vaccination place is inconvenient69.312.89.58.3
    Spend long time waiting for taking influenza vaccination62.520.511.35.7
    Don't know where to vaccinate73.211.68.96.3
    Influenza vaccination services are hard to make appointment67.917.69.84.8
    Confidence
    Being worried about adverse reactions50.321.421.76.5
    No influenza vaccination notification at workplace56.016.414.313.4
    Influenza vaccine is not effective49.425.020.25.4
    Having contraindications56.019.616.18.3
    Pregnant or lactating67.014.610.18.3
    Complacency
    Influenza will not cause severe illness31.325.332.111.3
    Abbreviation: PHWs=public health workers.

    Table 1.  Reasons for influenza vaccine hesitancy among PHWs (Based on 3Cs model) in China, September 2022.

    Of the 94.2% (2,945/3,127) of respondents who were willing to recommend influenza vaccines to others, no requirements at the government or workplace level for recommendation, fear of misinterpreting recommendation as having commercial interests, and potential adverse reactions were their primary concerns. Of the remaining respondents who were unwilling to recommend influenza vaccines, no requirements at the government or workplace level for recommendation and potential adverse reactions of influenza vaccines were their primary concerns (Table 2).

    VariableTotal (n, %)Willing to recommend (n, %)
    Worried about the misunderstanding of commercial interests by recipients1,440 (46.1)1,387 (47.1)
    Worried about the adverse reactions of recipients1,313 (42.0)1,252 (42.5)
    No recommendation on requirement by national authorities or at workplace1,312 (42.0)1,233 (41.9)
    Pregnancy or have contraindications1,123 (35.9)1,068 (36.3)
    Influenza won't cause severe illness and vaccination is unnecessary1,065 (34.1)1,004 (34.1)
    Worried about the medical tangle caused by recommendation927 (29.6)886 (30.1)
    Influenza vaccine is not effective861 (27.5)819 (27.8)
    Due to self-unvaccinated and lack of influenza vaccine confidence596 (19.1)551 (18.7)
    Influenza vaccination is inconvenient354 (11.3)336 (11.4)
    Abbreviation: PHWs=public health workers.

    Table 2.  Reasons for influenza vaccine recommendation among PHWs in China, September 2022.

    According to the results of univariate analysis, vaccine hesitancy was high among PHWs who did not receive an influenza vaccine in the 2021–2022 season (19.7%), who reported the payment method was inconvenient (15.7%), who were not concerned about the risk of influenza in the 2022–2023 season (14.7%), and who believed influenza vaccination was not important to health (65.6%) (Table 3).

    VariableTotal (n, %)Vaccination willingness (n, %)Vaccine hesitancy
    (n, %)
    Univariate analysisLogistic regression analysis
    χ2P for chi-square testOR (95% CI)P-value
    PLAD by GDP per capita*
    Low GDP area680 (21.7)588 (86.5)92 (13.5)8.810.012Ref
    Middle GDP area1,413 (45.2)1,262 (89.3)151 (10.7)0.85 (0.61–1.19)0.346
    High GDP area1,034 (33.1)941 (91.0)93 (9.0)0.61 (0.43–0.88)0.008
    Type of workplace
    Community health service centers/Township health centers2,304 (73.7)2,043 (88.7)261 (11.3)3.100.078Ref
    Center for Disease Control and Prevention823 (26.3)748 (90.9)75 (9.1)0.86 (0.60–1.22)0.392
    Professional title
    None347 (11.1)296 (85.3)51 (14.7)8.880.031Ref
    Junior1,206 (38.6)1,070 (88.7)136 (11.3)1.21 (0.78–1.86)0.397
    Middle1,212 (38.8)1,095 (90.3)117 (9.7)1.19 (0.76–1.87)0.446
    Senior362 (11.6)330 (91.2)32 (8.8)1.25 (0.70–2.23)0.458
    Chronic diseases history (Except for simple hypertension)
    Yes153 (4.9)133 (86.9)20 (13.1)3.370.185Ref
    No2,922 (93.4)2,615 (89.5)307 (10.5)0.51 (0.28–0.94)0.030
    Unclear52 (1.7)43 (82.7)9 (17.3)0.72 (0.26–2.03)0.538
    Influenza infection history since September 2021
    Yes424 (13.6)400 (94.3)24 (5.7)13.260.001Ref
    No2,176 (69.6)1,926 (88.5)250 (11.5)1.98 (1.21–3.24)0.006
    Unclear527 (16.9)465 (88.2)62 (11.8)1.98 (1.14–3.42)0.015
    Received influenza vaccine between September 2021 and April 2022
    Yes1,643 (52.5)1,600 (97.4)43 (2.6)238.48<0.001Ref<0.001
    No1,484 (47.5)1,191 (80.3)293 (19.7)5.08 (3.54–7.29)
    On-site vaccination at workplace
    Yes2,650 (84.7)2,400 (90.6)250 (9.4)31.60<0.001Ref
    No403 (12.9)332 (82.4)71 (17.6)1.50 (1.03–2.20)0.037
    Unclear74 (2.4)59 (79.7)15 (20.3)1.47 (0.71–3.07)0.303
    Ways of influenza vaccine payment
    Self-paid2,333 (74.6)2,047 (87.7)286 (12.3)43.49<0.001Ref
    Free329 (10.5)313 (95.1)16 (4.9)0.60 (0.31–1.17)0.132
    Employer paid225 (7.2)214 (95.1)11 (4.9)0.89 (0.43–1.87)0.763
    Medical insurance208 (6.7)188 (90.4)20 (9.6)0.63 (0.36–1.11)0.111
    Unclear32 (1.0)29 (90.6)3 (9.4)0.39 (0.10–1.58)0.185
    Convenience of payment method
    Very convenient973 (31.1)910 (93.5)63 (6.5)43.49<0.001Ref
    Moderately convenient1,295 (41.4)1,157 (89.3)138 (10.7)0.95 (0.66–1.39)0.807
    A little convenient558 (17.8)463 (83.0)95 (17.0)1.32 (0.86–2.01)0.202
    Not at all convenient301 (9.6)261 (86.7)40 (13.3)1.10 (0.65–1.86)0.717
    Perceived risk of influenza this season
    Very concerned132 (4.2)130 (98.5)2 (1.5)41.06<0.001Ref
    Moderately concerned243 (7.8)230 (94.7)13 (5.3)2.53 (0.48–13.47)0.276
    A little concerned1,590 (50.8)1,440 (90.6)150 (9.4)3.11 (0.64–15.04)0.158
    Not at all concerned1,162 (37.2)991 (85.3)171 (14.7)5.26 (1.09–25.41)0.039
    Health influence of the influenza vaccine
    Very important1,531 (49.0)1,482 (96.8)49 (3.2)396.93<0.001Ref
    Moderately important1,055 (33.7)932 (88.3)123 (11.7)2.50 (1.71–3.64)<0.001
    A little important480 (15.4)356 (74.2)124 (25.8)4.21 (2.81–6.30)<0.001
    Not at all important61 (2.0)21 (34.4)40 (65.6)21.32 (10.15–44.80)<0.001
    Whether the trivalent or quadrivalent influenza vaccine affects willingness
    No1,137 (36.4)975 (85.8)162 (14.2)22.86<0.001Ref
    Yes1,990 (63.6)1,816 (91.3)174 (8.7)0.97 (0.72–1.31)0.836
    Whether the inactivated or live-attenuated vaccine influences willingness
    No1,325 (42.4)1,139 (86.0)186 (14.0)25.99<0.001Ref
    Yes1,802 (57.6)1,652 (91.7)150 (8.3)0.66 (0.49–0.89)0.006
    Workplace vaccination policy (free for all staff)
    Yes810 (25.9)766 (94.6)44 (5.4)34.16<0.001Ref
    No2,038 (65.2)1,788 (87.7)250 (12.3)0.88 (0.55–1.41)0.602
    Unclear279 (8.9)237 (84.9)42 (15.1)0.70 (0.39–1.28)0.248
    Expectation from colleagues toward influenza vaccination this season
    No65 (2.1)44 (67.7)21 (32.3)213.15<0.001Ref
    Yes1,715 (54.8)1,653 (96.4)62 (3.6)0.18 (0.09–0.37)<0.001
    Unclear1,347 (43.1)1,094 (81.2)253 (18.8)0.58 (0.28–1.19)0.135
    Attitudes toward influenza vaccine this season at your workplace
    Required343 (11.0)328 (95.6)15 (4.4)94.5<0.001Ref
    Encouraged1,038 (33.2)978 (94.2)60 (5.8)1.15 (0.59–2.25)0.678
    Neutrality1,442 (46.1)1,249 (86.6)193 (13.4)1.42 (0.73–2.74)0.301
    Unclear304 (9.7)236 (77.6)68 (22.4)1.57 (0.76–3.23)0.219
    How extensive do you consider your knowledge of the influenza vaccine
    Very confident1,361 (43.5)1,280 (94.0)81 (6.0)88.5<0.001Ref
    Moderately confident1,181 (37.8)1,044 (88.4)137 (11.6)1.22 (0.87–1.72)0.252
    A little confident447 (14.3)354 (79.2)93 (20.8)1.45 (0.98–2.16)0.065
    Not at all confident138 (4.4)113 (81.9)25 (18.1)  1.66 (0.91–3.03)0.101
    Abbreviations: OR=adds ratio; CI=confidence interval.
    * In terms of GDP per capita, provincial-level administrative divisions (PLADs) are divided into three levels: low, middle and high.
    Low for Anhui, Qinghai, Jiangxi, Shanxi, Heilongjiang, Guangxi, Guizhou,Yunnan, Gansu;
    Middle for Chongqing, Shaanxi, Liaoning, Jilin, Hunan, Hainan, Henan, Sichuan, Hebei;
    High for Beijing, Shanghai, Tianjin, Jiangsu, Zhejiang, Fujian, Guangdong, Shandong, Inner Mongolia, Hubei.

    Table 3.  Univariate analysis and multivariable logistic regression analysis of influenza vaccine hesitancy among public health workers in China, September 2022 (ref: willing to vaccination).

    Multivariable logistic regression analysis was used to assess factors associated with influenza vaccine hesitancy among PHWs. Those who had no influenza infection history (OR=1.98, 95% CI: 1.21–3.24), who did not receive an influenza vaccine between September 2021 and April 2022 (OR=5.08, 95% CI: 3.54–7.29), who could not receive on-site vaccination at workplace (OR=1.50, 95% CI: 1.03–2.20), who were not concerned about the risk of influenza this year (OR=5.26, 95% CI: 1.09–25.41), who believed the health influence of influenza vaccine is not important at all (OR=21.32, 95% CI: 10.15–44.80), a little important (OR=4.21, 95% CI: 2.81–6.30) and moderately important (OR=2.50, 95% CI: 1.71–3.64) were more likely to have hesitation toward influenza vaccination (Table 3).

    • The study found that 10.7% of PHWs were hesitant to get vaccinated against influenza during the COVID-19 pandemic. 52.5% of PHWs were vaccinated in the 2021–2022 season, which was higher than the 35.4% among respiratory care practitioners in the same season and 11.6% among HCWs in the 2018–2019 season (4-5). Although the influenza vaccination coverage in this survey is fairly optimistic, the small proportion of influenza vaccination hesitancy among PHWs still needs attention. The most cost-effective way to prevent influenza and its complications is annual vaccination, especially during the COVID-19 pandemic. As a high-risk population, PHWs vaccination against influenza not only reduces the harm from associated diseases and the use of medical resources, but also promotes health information communication and public confidence in influenza vaccination. The study elucidated primary concerns or no mandatory government or workplace recommendations for vaccination and vaccine safety among PHWs. In the interest of self-protection, potential adverse reactions to vaccines affect PHW willingness to recommend vaccines (9).

      The study also suggested that complacency remains the biggest driver to influenza vaccine hesitancy and has the greatest impact on the willingness of PHWs to get vaccinated. Among the 336 hesitant PHWs, those without influenza infection and vaccination history were more prone to vaccine hesitancy, and those who did not worry about getting influenza in the current season or did not believe getting an influenza vaccination was important were at higher risk. Since the COVID-19 outbreak, public health interventions such as mask-wearing and social distancing have reduced influenza activity significantly. However, the measures also led to a decline in existing immunity and increased susceptibility to influenza. An increasing trend of influenza activity was observed in the northern hemisphere, highlighting the need for close monitorization and preparation for the co-circulation of influenza viruses and severe acute respiratory syndrome coronavirus 2 (10). PHWs need to be fully aware of the severity of influenza and the necessity for influenza vaccination as well as extensively understand the burden of influenza disease and prevention and control strategies during the COVID-19 pandemic. This helps reduce hesitancy toward influenza vaccines. Similar to other studies (4), the convenience of vaccination services is also an important factor for PHWs considering vaccination. Over the past year, many vaccination facilities have been used for COVID-19 vaccination, affecting the accessibility of influenza vaccines. The influenza vaccination payment did not affect the will of PHWs from this study. Generally, the first concern of PHWs with the medical background was the safety and effectiveness of vaccines. Influenza vaccine payment did not directly impact their vaccination decisions and intentions.

      This study has some limitations. First, in the interest of quick, simple and feasible survey results, the online questionnaire was a quantitative survey without individual interviews. The results of the study were influenced by the cooperative attitude of the participants. Second, individual indicators vary considerably, and further expansion of the sample size is recommended. Third, specific differences could not be analyzed as the matrix questionnaire was used for PHWs’ intention to recommend influenza vaccine.

      In conclusion, in the context of the potential co-circulation of influenza and COVID-19 in Winter 2022–2023, targeted interventions are needed among HCWs to improve influenza vaccination attitudes and behaviors, reduce the social hazards of influenza and protect the health of the population at large.

    • No conflicts of interest.

    • The participants’ contact information sharing as well as critical comments from the reviewers.

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