impact of severe acute respiratory syndrome and the perceived avian influenza epidemic on the...

Impact of Severe Acute Respiratory Syndrome and the Perceived Avian Influenza Epidemic onthe Increased Rate of Influenza Vaccination Among Nurses in Hong Kong • Author(s): Dennise K. P. Tam , BSocSc; Shui‐Shan Lee , MD; Sing Lee , FRCPsych(UK)Source: Infection Control and Hospital Epidemiology, Vol. 29, No. 3 (March 2008), pp. 256-261Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/527507 .

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infection control and hospital epidemiology march 2008, vol. 29, no. 3

o r i g i n a l a r t i c l e

Impact of Severe Acute Respiratory Syndrome and the PerceivedAvian Influenza Epidemic on the Increased Rate of Influenza

Vaccination Among Nurses in Hong Kong

Dennise K. P. Tam, BSocSc; Shui-Shan Lee, MD; Sing Lee, FRCPsych(UK)

objective. To determine the rate of influenza vaccination and the factors associated with the vaccination’s acceptance among nursesin Hong Kong.

design. Cross-sectional survey.

participants. Nurses practicing between 2003 and 2007.

methods. A questionnaire was sent to all nurses registered with any of the 3 nursing associations that participated in this study.

results. A total of 941 completed questionnaires were available for analysis, though not all nurses responded to every question (responserate, 33.5%-36.3%). Vaccination rates in 2006 and 2007 were 57.2% and 46.2%, respectively. Nurses who were vaccinated in 2006 weremore likely to get vaccinated in 2007 ( ); 56% of the nurses perceived influenza vaccine as being effective against influenza. TheP ! .01perceived effectiveness of influenza vaccine was a consistent predictor of rates of vaccination in 2006 (odds ratio [OR], 8.47 [95% confidenceinterval {CI}, 6.13-11.70]; ) and 2007 (OR, 6.05 [95% CI, 3.79-9.67]; ). Concern about contracting avian influenza was aP ! .01 P ! .01predictor of the vaccination rate in 2006 but not in 2007 (OR, 1.47 [95% CI, 1.03-2.09]; ), as was the perceived lack of controlP ! .05over avian influenza infection (OR, 1.52 [95% CI, 1.06-2.18]; ).P ! .05

conclusions. The overall influenza vaccination rate for nurses in Hong Kong was about 50%. It was affected by the perceived threatof an impending outbreak. The attitudes of nurses toward the effectiveness of and rationale for vaccination were a major barrier to increasingthe rate of vaccination.

Infect Control Hosp Epidemiol 2008; 29:256-261

From the Stanley Ho Centre for Emerging Infectious Diseases (D.K.P.T., S.-S.L.) and the Department of Psychiatry (S.L.), The Chinese University of HongKong, Hong Kong, China.

Received June 27, 2007; accepted November 13, 2007; electronically published January 18, 2008.� 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2903-0009$15.00. DOI: 10.1086/527507

Influenza vaccine not only protects healthcare workers fromcontracting influenza but also reduces the chance of virus trans-mission within healthcare settings. However, for healthcareworkers, the rate of vaccination is unsatisfactorily low. In theUnited States, for example, the rates of vaccination amonghealthcare workers are in the range of 30.2%-73%.1-7 In Aus-tralia, a study demonstrated an overall 38% rate of vaccinationin a public hospital.8 In Germany, a selected group of healthcareworkers from 20 hospitals showed an increase in the rate ofvaccination (from 21% to 26%) after a nationwide campaign,but the rate remained very low.9 In the United Kingdom, therate of vaccination for doctors was 48.4%, whereas that fornurses was only 22.8%.10 Another study of British nurses andhealthcare assistants in Liverpool revealed that only 7.6% werevaccinated.11 One major barrier to vaccination was the mis-conception by healthcare workers about the rationale for get-ting vaccinated.12,13 Other reasons for not getting vaccinatedincluded the perceived ineffectiveness of the vaccine, the per-

ceived unlikelihood of contracting influenza, the potential sideeffects, fear of injection, and the lack of time for gettingvaccinated.2,6,11,12,14-17

In addition to personal reasons, other situational factorsmay affect the rate of vaccination. For example, severe acuterespiratory syndrome (SARS) was a situational factor that hasaffected people’s health-related behavior. In Hong Kong,wearing a mask, ensuring proper hand washing, and usinghousehold disinfectants were 3 common preventive behaviorsadopted during the SARS outbreak.18 More recently, a surveydemonstrated that the general public was likely to adopt self-protective measures to decrease the risk of contracting avianinfluenza, such as wearing face masks and increasing the fre-quency of handwashing.19 Getting vaccinated against influ-enza can also be considered as preventive behavior, eventhough it can prevent neither SARS nor avian influenza, andwe hypothesize that the SARS outbreak and the concern aboutan impending avian influenza epidemic, along with personal



sars, avian influenza, and nurse vaccination rates 257

table 1. Characteristics of Nurses Who Re-sponded to the Influenza Vaccination Questionnaire

CharacteristicProportion (%)of respondents

AgeX25 years 13/933 (1.4)26-35 years 214/933 (22.9)36-45 years 434/933 (46.5)46-55 years 249/933 (26.7)x56 years 23/933 (2.5)

SexMale 106/904 (11.7)Female 798/904 (88.3)

Duration of employmentX1 year 6/905 (0.7)2-5 years 35/905 (3.9)6-10 years 107/905 (11.8)11-20 years 380/905 (42.0)x21 years 377/905 (41.7)

Nursing practicea

Registered 688/904 (76.1)Enrolled 216/904 (23.9)

Type of contact with patientsFrequent 713/937 (76.1)Normalb 81/937 (8.6)Infrequent 85/937 (9.1)None 58/937 (6.2)

note. Not all nurses responded to every question.a Registered nurses completed 3 years of training in arecognized training school or a degree or diploma in nurs-ing or equivalent. Enrolled nurses completed 2 years oftraining under a hospital-based program in a recognizedtraining school.b Direct contact is involved, but not frequent.

reasons, might have contributed to the increase in the rateof vaccination among healthcare workers. In Hong Kong, theprevious SARS outbreak and the threat of an impending avianinfluenza epidemic provided us with a unique opportunityto carry out a study that investigated their impact in a health-care setting.

methods

Nurses in Hong Kong were targeted in a self-administeredquestionnaire survey to assess their experience with SARS,their attitudes toward an impending avian influenza epi-demic, and their views on getting vaccinated. Nurses whoregistered as members of the Hong Kong Nurses GeneralUnion (the Nurses Branch, the Enrolled Nurses Branch, and/or Hong Kong Chinese Civil Servants’ Association) were in-vited to participate in this study. Memberships of the 3 or-ganizations are not mutually exclusive, and all nursespracticing in Hong Kong are eligible for registration. Thequestionnaire, which was attached to an introductory letterexplaining the nature of the study and the protection of an-onymity, was sent to a member’s postal address. Because al-most all nurses in Hong Kong are Chinese, the questionnairewas constructed in Chinese, following discussion with therepresentatives of the nursing associations, and was pilot-tested before being administered. Ethical approval was ob-tained from the ethics committee of the Chinese Universityof Hong Kong.

The questionnaire was divided into 3 main parts. In thefirst part of the questionnaire, respondents were asked toprovide their age, sex, and their years of service. They werealso asked about the nature of their job during the SARSoutbreak. In the second part, respondents were asked abouttheir vaccination status in 2006 and their intention to getvaccination in 2007. Respondents were also asked to indicatethe reasons for and barriers to receiving vaccination and theirperception of the effectiveness of the vaccine. In the thirdpart, respondents were asked about their attitudes toward animpending avian influenza epidemic in Hong Kong. Thequestions were adapted from the study by Imai et al.20 A 6-point Likert scale was used to assess respondents’ perceptionsof the likelihood of an avian influenza epidemic in HongKong, their perceptions of control of the infection, and theirperceptions of the risk of contracting avian influenza in re-lation to their work.

Statistical analysis was performed with SPSS (version 13.0).The odds ratio (OR) was used to calculate group differencesin categorical data. Data were further analyzed by multivariateanalysis, with statistical significance defined as .P ! .05

results

Characteristics of Respondents

In the second week of September 2006, a total of 2,929 ques-tionnaires were mailed; 104 of these questionnaires were not

delivered owing to incorrect postal addresses. We collected946 completed questionnaires over a 4-week period in Sep-tember and October 2006; however, not all respondents an-swered every question. Three of the respondents had retiredbefore 2003, and 2 gave incomplete responses; these wereexcluded from final data analysis. In calculating the responserate, we assumed that 10% of the respondents had enrolledin 2 of the associations listed above and that about 2% ofour sample was not actively practicing.21 The response rateof our study thus fell between 33.5% and 36.3%.

Of the 941 respondents who returned questionnaires avail-able for data analysis, it was found that 831 (88.3%) werefemale and that 716 (76.1%) provided direct patient care.About half of the respondents (438 [46.5%]) were 36-45 yearsof age. The majority (367 [83.7%]) of them had been workingin the profession for more than 11 years (Table 1).

Vaccination

Slightly more than half of the respondents (538 [57.2%] of941) had received influenza vaccination in 2006. With respectto the intention to be vaccinated in 2007, there were 435



258 infection control and hospital epidemiology march 2008, vol. 29, no. 3

table 2. Rates of and Reasons for Influenza Vaccination Among Nurses WhoResponded to the Questionnaire

Characteristic

Proportion (%) of respondents

Vaccinated in 2006Intention to be

vaccinated in 2007

Vaccinated 538/941 (57.2) 435/941 (46.2)Reasons for getting vaccinated

Self-protection 401/534 (75.1) 337/435 (77.5)Protection of others 173/534 (32.4) 163/435 (37.5)Required by work 205/534 (38.4) 153/435 (35.2)

Reasons for not getting vaccinatedIneffective in self-protection 205/382 (53.7) 218/342 (63.7)Ineffective in protecting others 40/382 (10.5) 33/342 (9.6)Side effects 164/382 (42.9) 136/342 (39.8)Not required by work 28/382 (7.3) 16/342 (4.7)Medical condition 14/382 (3.7) 2/342 (0.6)Do not need the vaccine 31/382 (8.1) 30/342 (8.8)

note. Not all nurses responded to every question.

(46.2%) respondents who indicated that they would do so inthe coming year, 348 (37.0%) who indicated that they wouldnot, and 158 (16.8%) who were undecided. During the yearsof 2006 and 2007, the reasons for getting vaccinated weresimilar, and they are listed in Table 2.

About half of the respondents (521 [55.7%] of 935) per-ceived the vaccine as an effective means to protect themselvesfrom contracting influenza. This perception was significantlyassociated with vaccination acceptance in both 2006 (OR, 7.69[95% confidence interval {CI}, 5.75-10.31]) and 2007 (OR,11.10 [95% CI, 8.09-15.23]). Furthermore, respondents whowere vaccinated in 2006 were more likely to be vaccinated in2007 (OR, 98.64 [95% CI, 55.73-174.60]).

Impact of SARS and the Threat of an AvianInfluenza Epidemic

During the SARS epidemic, 448 (48.1%) of 931 respondentsworked in wards or hospitals with SARS patients. About 300(32%) of them did not perform any SARS-related duties. Theremaining 183 respondents (20%) carried out duties that didnot involve direct interactions with SARS patients, such aspublic education, infection control, and quarantine of resi-dents of Amoy Gardens (the housing estate in Hong Kongwhere a community outbreak of SARS took place).

Regarding the attitudes toward an impending avian influ-enza epidemic, less than half of the respondents (426 [45.4%]of 938) considered that it would take place in Hong Kong.Although the majority of them were afraid of contractingavian influenza (636 [68.0%] of 936) and perceived limitedcontrol over their risk of contracting the virus because of thenature of their work (681 [72.4%] of 941), most of themaccepted the risk of infection as part of their work (678[72.1%] of 940). A small proportion of them believed thatthey should not take care of patients with avian influenza

(128 [13.6%] of 939) and would consider a job change toavoid the risk of infection (204 [21.7%] of 941).

We calculated the ORs for the associations between ex-perience of SARS and/or concern about of an avian influenzaepidemic and acceptance of influenza vaccination (Table 3).Concern about the risk of contracting avian influenza wasassociated with acceptance of vaccination in 2006. The in-tention to get vaccinated in 2007 was associated with neitherSARS experience nor concern about an impending avian in-fluenza epidemic.

Predictors of Vaccination

Two logistic regression analyses were performed to explorethe predictors of the rates of vaccination in 2006 and 2007,controlling for age, sex, and work experience (Table 4). Vac-cination in 2006 was the outcome measure in the first re-gression model. Results show that the fear of contractingavian influenza, the perceived limited control over avian in-fluenza infection, and the perceived effectiveness of influenzavaccine were associated with acceptance of vaccination in2006. The second regression model measured the predictorsof the intention to be vaccinated in 2007. The perceived ef-fectiveness of the vaccine and vaccination in 2006 were alsosignificant predictors in this model. Interestingly, nurses whodid not perform direct patient care duties had the highestintention to get vaccinated.

discussion

To our knowledge, this is the first study of the acceptance bynurses of yearly influenza vaccination in Hong Kong. Wefound a vaccination rate of approximately 50%, which washigher than that reported in UK, France, Spain, andAustralia.8,10,22,23 Despite the encouraging finding, we are con-cerned about the decrease in vaccination acceptance in 2007,




table 3. Associations Between Experience of Severe Acute Respiratory Syndrome (SARS), Concern About Avian Influenza,and Acceptance of Influenza Vaccination

Variable

Vaccinated in 2006Intention to be

vaccinated in 2007

Proportion (%)of respondents OR (95% CI)

Proportion (%)of respondents OR (95% CI)

SARS experienceHad SARS-related duties 358/630 (56.8) 0.98 (0.74-1.30) 290/630 (46.0) 1.01 (0.77-1.33)Had no SARS-related duties 172/300 (57.3) 137/300 (45.7)

Concern about avian influenzaPerceived that there might be an upcoming

avian influenza outbreak in Hong KongYes 243/426 (57.0) 0.99 (0.76-1.28) 198/426 (46.5) 1.02 (0.79-1.33)No 294/512 (57.4) 235/512 (45.9)

Afraid of contracting avian influenzaYes 387/635 (60.9) 1.56 (1.18-2.06) 309/636 (48.6) 1.31 (0.99-1.72)No 150/300 (50.0) 126/300 (42.0)

Perceived limited control over the risk ofcontracting avian influenza

Yes 401/680 (59.0) 1.29 (0.97-1.72) 325/681 (47.7) 1.25 (0.93-1.66)No 137/260 (52.7) 110/260 (42.3)

Accepted the risk of contracting avian influenzain the course of work

Yes 386/678 (56.9) 0.95 (0.71-1.27) 320/678 (47.2) 1.14 (0.86-1.52)No 152/261 (58.2) 115/262 (43.9)

Would consider job change if required to takecare of patients with avian influenza

Yes 122/203 (60.1) 1.16 (0.85-1.60) 96/204 (47.1) 1.04 (0.77-1.42)No 416/737 (56.4) 339/737 (46.0)

Believed he/she should not take care of patientswith avian influenza

Yes 79/127 (62.2) 1.27 (0.86-1.87) 60/128 (46.9) 1.03 (0.71-1.50)No 458/811 (56.5) 374/811 (46.1)

note. CI, confidence interval; OR, odds ratio. Not all nurses responded to every question.

compared with the previous year. We have thus exploredwhether the factors associated with vaccination acceptancewere different for these 2 years.

In 2005, the threat of an impending human-to-humanavian influenza epidemic in Hong Kong had driven the gov-ernment and the society at large to get prepared for the chal-lenge.24 Nurses who were afraid of the infection and whoperceived the risk of infection as uncontrollable were morelikely to get vaccinated in 2006. By the end of 2006 influenzaseason, an avian influenza epidemic had not happened.Therefore, the impact of this impending threat on rates ofinfluenza vaccination was greatly diminished in 2007, as re-flected in the present study.

The SARS outbreak of 2003 heightened public awarenessof personal hygiene and increased health-seeking behavior inHong Kong.25 We hypothesized that it might affect the ratesof influenza vaccination in the following years. However, ourdata did not support this hypothesis. Three reasons mightexplain our findings. First, the outbreak of SARS happened3 years ago. Compared with the more current threat of animpending avian influenza epidemic, SARS was very unlikely

to be of immediate concern. Second, Hong Kong had main-tained a high level of vigilance in preparing for another SARSepidemic,26 but this vigilance has diminished. The publicmight have become desensitized, and the impact of SARS onthe rate of influenza vaccination is therefore much lower thananticipated. Third, although both avian influenza and SARSare infectious diseases, the former is associated with a virusthat belongs to the same influenza family. It is therefore notsurprising to find that the threat of avian influenza had astonger influence on rates of vaccination than the threat ofSARS. We could not exclude the possibility that SARS mighthave had an impact on the acceptance of influenza vacci-nation in 2004 and 2005. However, this could not be con-firmed in the present study.

We might consider the increase in rates of influenza vac-cination as a positive effect of the threat of an impendingavian influenza epidemic, but we should not rely on suchthreats alone to maintain a high vaccination rate in healthcaresettings. In developing strategies to increase and maintainvaccination rates, we need to look at determinants that aremodifiable—in this case, the attitudes of nurses. Some nurses



260 infection control and hospital epidemiology march 2008, vol. 29, no. 3

table 4. Factors Associated With Acceptance of Vaccination Among NursesWho Responded to the Questionnaire

Variable

OR (95% CI), by respondent group

Vaccinatedin 2006

Intention to bevaccinated in 2007

AgeX25 years 1.00 1.0026-35 years 3.64 (0.36-36.6) 0.18 (0.01-3.42)36-45 years 2.08 (0.58-7.41) 0.41 (0.05-3.23)46-55 years 2.11 (0.67-6.62) 0.79 (0.12-5.38)x56 years 1.90 (0.62-5.75) 1.04 (0.16-6.77)

SexFemale 1.22 (0.74-2.00) 0.69 (0.33-1.47)Male 1.00 1.00

Nursing practiceRegistered 1.00 (0.68-1.48) 1.49 (0.88-2.53)Enrolled 1.00 1.00

Years of serviceX1 year 0.45 (0.03-7.29) 13.22 (0.25-702.98)2-5 years 1.19 (0.42-3.38) 2.63 (0.56-12.42)6-10 years 0.63 (0.30-1.36) 1.05 (0.36-3.03)11-20 years 1.01 (0.62-1.63) 1.08 (0.53-2.21)x21 years 1.00 1.00

Contact with patientsFrequent 1.00 1.00Normal 1.03 (0.58-1.83) 1.42 (0.58-3.49)Infrequent 1.44 (0.79-2.63) 1.68 (0.74-3.83)None 1.90 (0.95-3.78) 4.52 (1.44-14.22)

Afraid of contracting avian influenzaYes 1.47 (1.03-2.09) 0.97 (0.57-1.64)No 1.00 1.00

Perceived limited control over riskof contracting avian influenza

Yes 1.52 (1.06-2.18) 1.27 (0.75-2.16)No 1.00 1.00

Perceived vaccine to be effectiveYes 8.47 (6.13-11.70) 6.05 (3.79-9.67)No 1.00 1.00

Vaccinated in 2006Yes … 87.50 (44.97-170.23)No … 1.00

note. CI, confidence interval; OR, odds ratio.

refused vaccination because it could only protect them fromselected virus strains over a limited time period. On the otherhand, the majority of nurses did not identify with the primaryobjective of providing influenza vaccination in the healthcaresetting. Only about 30% of our sample regarded “the needto protect others” as a major determinant of their gettingvaccinated. In our study, nurses who worked in the field hada lower rate of vaccination, which may reflect their perceivedrisk of contracting the infection and their doubts about theefficacy of the vaccine. This attitude contrasts with the morepositive attitude of nurses who did not work in the field andwho may have in fact exhibited behavior similar to that ofthe general public.

A vaccination campaign has been shown to be effective in

increasing the immediate rate of vaccination. In addition tosuch a campaign, use of an information-processing model isparticularly appropriate for sustaining an increase in the vac-cination rate in the long run.27 Healthcare workers should beinformed of the efficacy of influenza vaccine and the objec-tives of vaccination so that they can adjust their attitudestoward influenza vaccination. Furthermore, in agreementwith previous studies, we have found that the experience ofgetting vaccinated has had a positive influence on the like-lihood of getting vaccinated again subsequently.3,6,23 If vac-cination becomes a mandatory requirement for healthcareworkers or is made a professional standard, it should be ef-fective in maintaining an increase in the vaccination rate inthe healthcare setting.




Our study has 3 limitations. First, the data on vaccinationin 2007 were derived from the responses of nurses to a surveyquestion on one’s inclination to be vaccinated. We were un-able to collect data on the actual vaccination rate before theinfluenza vaccination program began. Second, we failed todemonstrate the impact of experience of SARS on the seasonalinfluenza vaccination rate over a 3-year period, because wewere unable to gather data on vaccination rates in 2004 and2005. Third, a self-reporting questionnaire may not reflectthe behavior of respondents in real-life situations. Also, amajority of our respondents were currently in practice. Wewere unable to get responses from nurses who had resignedbecause of their concern about contracting SARS or avianinfluenza.

In conclusion, Hong Kong has a satisfactory influenza vac-cination rate within the nursing profession. Acceptance ofvaccination was associated with the occurrence of a precedinghealth-related crisis. Developing a long-term monitoring sys-tem is important, to help keep track of the vaccination ratesin the health profession. This system would enable us todetermine whether a concurrent or impending epidemicwould affect the rate of vaccination, and it would also helpinform policy makers on how to design effective strategies toimprove the rate of vaccination of healthcare workers.

acknowledgments

We thank the executive committee of the 3 nursing associations who helpedin recruiting subjects and in distributing the questionnaire pack to theirmembers.

Potential conflicts of interest. The authors report no conflicts of interestrelevant to this article.

Address reprint request to Shui-Shan Lee, Room 206, School of PublicHealth, Centre for Emerging Infectious Diseases, The Chinese Universityof Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China([email protected]).

references

1. Doebbeling BN, Edmond MB, Davis CS, Woodin JR, Zeitler RR. Influ-enza vaccination of health care workers: evaluation of factors that areimportant in acceptance. Prev Med 1997; 26:68-77.

2. LaVela SL, Legro MW, Weaver FM, Smith B. Staff influenza vaccination:lessons learned. SCI Nurs 2004; 21:153-157.

3. Piccirillo B, Gaeta T. Survey on use of and attitudes toward influenzavaccination among emergency department staff in a New York metro-politan hospital. Infect Control Hosp Epidemiol 2006; 27:618-622.

4. Martinello RA, Jones L, Topal JE. Correlation between healthcare work-ers’ knowledge of influenza vaccine and vaccine receipt. Infect ControlHosp Epidemiol 2003; 24:845-847.

5. Christini AB, Shutt KA, Byers KE. Influenza vaccination rates and mo-tivators among healthcare worker groups. Infect Control Hosp Epidemiol2007; 28:171-177.

6. Watanakunakorn C, Ellis G, Gemmel D. Attitude of healthcare personnelregarding influenza immunization. Infect Control Hosp Epidemiol 1993;14:17-20.

7. Wodi AP, Samy S, Ezeanolue E, et al. Influenza vaccine: immunizationrates, knowledge, and attitudes of resident physicians in an urban teach-ing hospital. Infect Control Hosp Epidemiol 2005; 26:867-873.

8. Bull AL, Bennett N, Pitcher HC, Russo PL, Richards MJ. Influenza vac-cine coverage among health care workers in Victorian public hospitals.Med J Aust 2007; 186:185-186.

9. Leitmeyer K, Buchholz U, Kramer M, et al. Influenza vaccination inGerman health care workers: effects and findings after two rounds of anationwide awareness campaign. Vaccine 2006; 24:7003-7008.

10. Qureshi AM, Hughes NJ, Murphy E, Primrose WR. Factors influencinguptake of influenza vaccination among hospital-based health care work-ers. Occup Med (Lond) 2004; 54:197-201.

11. Canning HS, Phillips J, Allsup S. Health care worker beliefs about in-fluenza vaccine and reasons for non-vaccination—a cross-sectional sur-vey. J Clin Nurs 2005; 14:922-925.

12. Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination ofhealthcare workers: a literature review of attitudes and beliefs. Infection2006; 34:142-147.

13. Willis BC, Wortley P. Nurses’ attitudes and beliefs about influenza andthe influenza vaccine: a summary of focus groups in Alabama and Mich-igan. Am J Infect Control 2007; 35:20-24.

14. O’Reilly FW, Cran GW, Stevens AB. Factors affecting influenza vaccineuptake among health care workers. Occup Med (Lond) 2005; 55:474-479.

15. Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers toinfluenza vaccine acceptance: a survey of physicians and nurses. Am JInfect Control 1989; 17:202-207.

16. Markey CS. Healthcare worker influenza vaccination: personal choice orprofessional responsibility? Home Healthc Nurse 2004; 22:643-644.

17. Tapiainen T, Bar G, Schaad UB, Heininger U. Influenza vaccinationamong healthcare workers in a university children’s hospital. Infect Con-trol Hosp Epidemiol 2005; 26:855-858.

18. Lau JT, Yang X, Tsui H, Kim JH. Monitoring community responses tothe SARS epidemic in Hong Kong: from day 10 to day 62. J EpidemiolCommunity Health 2003; 57:864-870.

19. Lau JT, Kim JH, Tsui HY, Griffiths S. Anticipated and current preventivebehaviors in response to an anticipated human-to-human H5N1 epi-demic in the Hong Kong Chinese general population. BMC Infect Dis2007; 7:18.

20. Imai T, Takahashi K, Hasegawa N, Lim MK, Koh D. SARS risk percep-tions in healthcare workers, Japan. Emerg Infect Dis 2005; 11:404-410.

21. Tam DKP, Lee SS, Lee S. Impact of SARS on avian influenza preparednessin healthcare workers. Infection 2007; 35:320-325.

22. Trivalle C, Okenge E, Hamon B, Taillandier J, Falissard B. Factors thatinfluence influenza vaccination among healthcare workers in a Frenchgeriatric hospital. Infect Control Hosp Epidemiol 2006; 27:1278-1280.

23. Bautista D, Vila B, Uso R, Tellez M, Zanon V. Predisposing, reinforcing,and enabling factors influencing influenza vaccination acceptance amonghealthcare workers. Infect Control Hosp Epidemiol 2006; 27:73-77.

24. Cameron PA, Schull M, Cooke M. The impending influenza pandemic:lessons from SARS for hospital practice. Med J Aust 2006; 185:189-190.

25. Lau JT, Yang X, Tsui HY, Kim JH. Impacts of SARS on health-seekingbehaviors in general population in Hong Kong. Prev Med 2005; 41:454-462.

26. Lee SH. Vigorous controls minimise risk. J Epidemiol Community Health2003; 57:774-775.

27. Bettinghaus EP. Health promotion and the knowledge-attitude-behaviorcontinuum. Prev Med 1986; 15:475-491.



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