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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 9-15

Vaccination of healthcare workers in Nigeria: A review of barriers, policies and level of implementation


1 Department of Community Medicine, University of Medical Sciences, Ondo City, Ondo State, Nigeria
2 Department of Community Health, University of Medical Sciences Teaching Hospital Complex, Ondo City, Ondo State, Nigeria

Date of Submission24-Jan-2020
Date of Acceptance15-Feb-2020
Date of Web Publication12-Mar-2020

Correspondence Address:
Dr. Olorunfemi Akinbode Ogundele
Department of Community Medicine, University of Medical Sciences, Ondo City, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_4_20

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  Abstract 


Health-care workers (HCWs) constitute a high-risk group frequently exposed to workplace hazards from contacts with infected body fluids. The World Health Organization recommends that high-risk groups, which include HCWs, be vaccinated against vaccine-preventable diseases considering their exposure risks. This review provides insight into vaccination coverage rates and barriers of vaccination of HCWs against vaccine-preventable diseases, especially hepatitis B virus (HBV) vaccination currently in place in Nigeria and provides recommendations for policy creation. A narrative review of peer-reviewed published original research, reports, and reviews was done after identifying relevant literature using Goggle Scholar as the major search engine. Peer-reviewed articles in databases such as PubMed, Medline, African Journals Online, and Google Scholar were reviewed. Nigeria, like many other countries in sub-Sahara Africa, has no clear policy on vaccination of HCWs against vaccine-preventable diseases; this constitutes a significant challenge that contributes to poor uptake of vaccination by HCWs. HBV is a major occupational health hazard that HCWs face in the course of their work. HCWs, in Nigeria, are at increased risk of hepatitis B infection because Nigeria is a holoendemic area. Lack of vaccination policy for HCWs, poor risk perception, cost of the vaccine, and unavailability of vaccine are some of the major barriers to vaccine uptake and coverage among HCWs. There is a need to create and appropriately implement policies explicitly meant for HCWs vaccination. Model program options that can be adopted across health institutions at an affordable cost are recommended.

Keywords: Barriers, health-care worker, hepatitis B, implementation, policies, vaccination


How to cite this article:
Ogundele OA, Omotosho AA. Vaccination of healthcare workers in Nigeria: A review of barriers, policies and level of implementation. Libyan J Med Sci 2020;4:9-15

How to cite this URL:
Ogundele OA, Omotosho AA. Vaccination of healthcare workers in Nigeria: A review of barriers, policies and level of implementation. Libyan J Med Sci [serial online] 2020 [cited 2022 Dec 2];4:9-15. Available from: https://www.ljmsonline.com/text.asp?2020/4/1/9/280564




  Introduction Top


Vaccination is one of the important health breakthroughs of the last century, and the use of vaccines is an effective tool available for the prevention of infectious diseases with their associated morbidities and mortalities.[1] Vaccines are highly cost-effective, efficient, and can be financially sustained even by the poorest of countries.[2] Uncontrolled infectious diseases can place a tremendous economic burden on countries, but immunization has increased life expectancy and general quality of life, with improvement in economic productivity globally.[3] The health-care workers (HCWs) constitute a high-risk group frequently exposed to workplace hazards from contacts with infected body fluids and tissues. HCWs refer to all health personnel regardless of training in medicine who have contact with the patients.[4] This group of workers are at various levels of exposure and contact with patients and include doctors, nurses, physiotherapists, waste handlers and health attendants, laboratory personnel, and administrative staff.[4],[5] The World Health Organization (WHO) recommends that high-risk groups, which include HCWs, be targeted for routine vaccination against vaccine-preventable diseases to protect from infections considering the risk of exposure. This recommendation is to assist government and health service providers in developing policies and formulating comprehensive vaccination strategies according to the local needs and disease prevalence to protect HCWs and for patient safety. In spite of the WHO recommendation, 24% of the HCWs worldwide remain unvaccinated. The effect is in significant morbidity and mortality due to vaccine-preventable diseases among HCWs.[6] Although HCWs are an easily identifiable group for the implementation of vaccination strategies, many countries face the challenge of addressing this group.[7] In the developed world, such as European countries where policies on vaccination of HCWs exist even though of various options (mandatory or voluntary policies), vaccination uptake remains poor at <25% among HCWs in such countries.[8],[9] In Nigeria, as may also be obtainable in some other sub-Sahara African countries, there is no vaccination policy explicitly meant for HCWs vaccination against vaccine-preventable disease. The vaccination plan for HCWs is just a subset of the National Vaccination Policy. This arrangement in itself is a significant challenge that contributes to the poor uptake of vaccination among HCWs in the country.[10]

Since there is no clear policy, the most appropriate time, perhaps for promoting the importance of HCWs vaccination will be during their preemployment medical screening. Mandatory vaccination integrated within the preemployment medical screening presents an appropriate national policy option to protect the HCWs, though this option comes with its challenges.

This review provides insight into HCWs vaccination coverage in Nigeria and the potential barriers to vaccination of HCWs, especially hepatitis B virus (HBV) vaccination and the current level of implementation in place in Nigeria. We also highlighted possible policy options and recommendations in response to these barriers peculiar to Nigeria with the hope that this information will guide in the development of appropriate policy options and implementation strategies in Nigeria and other sub-Sahara African countries.


  Methods Top


A narrative review of published original research, reports, and reviews was done after identifying relevant literature using Goggle Scholar as the major search engine. Peer-reviewed articles published between 1990 and 2018 in databases such as PubMed, Medline, African Journals Online, and Google Scholar were reviewed. A number of other documents, reports, and research briefs on hepatitis published in the English language by the WHO and centre for disease control (CDC) were also reviewed. We identified recent studies using the search words that include HBV, HCWs, vaccination, policies, and implementation. Only studies with accessible full texts were retrieved for the review. All study types were eligible for inclusion in the review. A total of 17 studies on HBV vaccination prevalence, barriers, policies, and current implementation state among HCWs in Nigeria were included in the study. Most of the studies accessed were cross sectional in design. Data on vaccination status and related information specific to HBV vaccination status, barriers, and policies were extracted from the studies. Documents on human resources for health were also reviewed.


  Results Top


Human resources in the Nigeria health sector

Nigeria has one of the largest human resources for health in Africa, comparable only to Egypt and South Africa.[11] The estimated population of the country as of 2012 was One hundred and sixty nine million, nineteen thousand, three hundred and twenty eighty.[12] Of this population, as estimated by the data are approximately 405,000 HCWs registered with various professional medical/health regulatory bodies. This figure includes those who work in the public and private sectors. There are about 39,210 doctors, 2773 dentists, and 124,629 nurses registered while others are community health practitioners, medical laboratory scientists, pharmacists, and others.[12] This figure is of importance as a rough estimate of HCWs who needs vaccination in Nigeria. The human resource challenges facing Nigeria's health sector include inappropriate policies and poor human resources management and development practices; inappropriate or inadequate training, poor access to information, and knowledge resources; and poor skills of HCWs, lack of supportive supervision, and unsafe conditions in the workplace.[11] These challenges increase the risk of contracting vaccine-preventable diseases among HCWs in the health-care setting in the country.

Importance of vaccination of health-care workers against vaccine-preventable diseases

Human resources are the backbone of health service delivery. The evidence for this is in the fact that HCWs numbers and quality have been positively associated with immunization coverage, increased outreach of primary health care, maternal, neonatal, and child survival services.[11] It is crucial to have a healthy workforce to offer, sustain, increase, and improve the coverage of quality health services. Vaccination is an important measure to keep a healthy workforce, prevent infectious diseases from spreading to people and is particularly important for HCWs who work closely with the patients. HCWs working directly with patients are at a higher risk of exposure to vaccine-preventable infections, and vaccination helps to protect them against these diseases. Reducing illness is essential for each HCW personal well-being and ensures his or her ability to perform the critical job functions of caring for patients. Vaccination is important to prevent the spread of disease from HCWs to patients, many of whom may be highly susceptible to infections and related complications and also to protect HCWs from acquiring these diseases and the resulting complications from these diseases. The WHO updated (2019) recommended vaccines for HCWs include Bacillus Calmette–Guérin, hepatitis B, polio, diphtheria, measles, rubella, meningococcal, influenza, varicella, and pertussis and also contains certain vaccines yet to be recommended [Table 1].[13] The information provided by the WHO is to assist countries in developing national policies for the vaccination of HCWs. It is expected that HCWs are fully vaccinated per the national vaccination schedule in use in their country[13] and according to local need and peculiarities.
Table 1: Vaccination recommendations for health-care workers

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Vaccination of health-care workers: An important component of universal safety precaution

The prevention of HBV transmission in health-care settings includes handwashing, surgical hand preparation, use of gloves, and safe handling and disposal of sharps, tissues, and waste. Other measures include safe cleaning of equipment, screening of donors, donated blood and blood products, improved access to safe blood, postexposure prophylaxis following needle-stick injury/sexual exposure/mucosal or percutaneous HBV exposure. Injection safety is also a vital safety measure requiring the use of auto-disable syringes for intramuscular, intradermal, and subcutaneous injections and a sufficient supply of quality-assured syringes with matching quantities of safety boxes in health-care setting.[14] However, total adherence to these safety measures does not suffice for the prevention of HBV. Vaccination of HCWs, especially if HBV surface antigen (HBsAg) is negative and capacity building of HCWs is a focal component of Universal safety precaution in the prevention of HBV transmission in the health-care setting. Vaccination and capacity building are measures that protects both the HCW and the patients as it remarkably reduces the risk of the infection, even among HCWs with high-risk exposure. The fact that vaccination reduces the risk of infection reinforces the vaccination of HCWs as an essential element of universal safety precaution.

Hepatitis B virus as a case study

Nigeria is one of the countries with a high burden of HBV with a prevalence of 11%. Medical personnel, especially surgeons and dentists, are at the highest risk of infection, while other HCWs, including nurses, ward attendants, and cleaners, are also at significant risk of infection.[15] HBV is the most important infectious occupational disease to which health workers are exposed.[14] The risk of being infected by HBV is dependent on the prevalence of the virus carriers in the environment, the frequency of exposure of the health worker to blood, and body fluids and the infectivity of the HBV.[16],[17]

The WHO projected that about two million HCWs are exposed to HBV annually and that 90% of the infections result from the exposures occurring in low-income countries, especially those in sub-Saharan Africa.[16],[17],[18] HCWs, in Nigeria, are particularly at increased risk because Nigeria is a holoendemic area with HBV carriage rate reported to be in the range of 9%–39% in the general populace[19] and about 1.5%–17% among HCWs.[20],[21],[22] Hepatitis B vaccination is the most important and effective way of controlling HBV infection.[23] HCWs can cause outbreaks in patients in the healthcare setting,[24] and therefore, their vaccination is a patient safety issue. Vaccination has been documented as the most effective and safest route of protection against disease outbreaks. The impact of such an outbreak among HCWs would be a breakdown in medical services.[4] The vaccination of HCWs reduces the transmission of infections in health-care settings, staff illness and absenteeism, morbidity, and mortality among persons at increased risk for contracting the disease. HCWs who are clinically or sub-clinically infected can transmit HBV virus to other persons. Decreasing the transmission of HBV from caregivers to persons at high risk or vice versa might reduce deaths among persons at high risk for the disease and its complications. HCWs play a vital role in promoting the changes in the behavior of the patients and even younger colleagues. A study in Europe that examined the obstacles to influenza vaccination found that the major reason why patients were not getting vaccinated was that the family physician never recommended it.[5] The mentoring leadership attitude of older HCWs can translate into helping younger colleagues who look up to them to receive their vaccination.[4] In addition to the often-pronounced hepatitis B vaccines, vaccination strategies regarding diseases that can be prevented by the vaccination should be considered. For example, the essential reason for the recommendation of booster shots against pertussis for the adolescents and adults, notwithstanding the complete cover of vaccination during childhood, is the risk of infecting the infants who have not developed immunity. For this reason, the vaccination of adults against pertussis might be important for HCWs and persons who are in close or constant contact with infants. This method is referred to as the “cocoon strategy.”[25] Vaccine-preventable diseases may result in direct and indirect costs in addition to their health consequences among HCWs. The direct costs include the costs incurred for the examinations, consultations, in-patient admission, and treatments required for the disease and its complications. Indirect costs, on the other hand, include the loss of work productivity and absenteeism.[5] The vaccination of HCWs is therefore essential in preventing this unnecessary cost.

Hepatitis B virus vaccination coverage rates, barriers, and level of implementation among health-care workers

In Nigeria, there is no published vaccination policy specific for HCWs vaccination against vaccine-preventable disease; however, the nation's guideline for the prevention, treatment, and care of viral hepatitis in Nigeria published in 2016 covers for HCWs in terms of the prevention of HBV transmission in the health-care setting. This document provides strategies toward achieving the global target of eliminating viral hepatitis by the year 2030. The strategies agreed upon at the 59th World Health Assembly of 2016 include; preventing mother to child transmission of viral hepatitis, reaching every child, adolescents, adults and high-risk population groups with HBV vaccination. This subgroup includes the HCWs and any other group at risk. Other strategies are ensuring safety of blood transfusion services, organ donation, injection practices and the use of new antiviral drug for treatment and cure of viral hepatitis.[13] According to the WHO estimate, HBV vaccination coverage among HCWs varies from 18%, with being the lowest in Africa and the highest in Australia and New Zealand at 77%.[17] Several studies have indicated the vaccination coverage rates of the hepatitis B vaccine among HCWs in Nigeria. A study conducted among HCWs in two teaching hospitals in Jos, North-Central Nigeria, and Yenagoa, South-South Nigeria revealed that 64.5% of the HCWs received at least one dose of HBV vaccine. In contrast, only 36.2% received full vaccine coverage of three doses. It is noteworthy that senior cadres of doctors, with longer work experience, and with prior training were more likely to be vaccinated than others.[26] A study in Irua Edo state found that though many of the respondents had a positive attitude toward the HBV infection and vaccine, about 70.2% of them had ever received HBV vaccine while only about three-fifths of those that started the vaccination program completed the schedule. Documented reasons from the study for not getting vaccinated are no reason/poor motivation, busy schedules, good practices of universal safety precaution, and poor risk perception.[27] Another study among HCWs in Ondo found that only 62.7% perceived self to be at high risk of contracting HBV infection, suggesting that quite a number of the HCWs (37.3%) perceived themself to be at low risk. The implication is that this group might be less keen on protecting themselves by receiving the HBV vaccine; this is because risk perception is a major component of awareness and willingness to protect themselves.[28] In another study done among all the categories of HCWs in the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, 22.4% of HCWs had received HBV vaccination. However, only 3.7% received adequate vaccination, which is three or more doses. HCWs perception of risk of contracting HBV in their workplace was suboptimal (50%) and worse among ward attendants (5.5%) as against 67.9% of other workers that felt that their jobs exposed them to increased risk. Poor perception is the likely reason for not receiving the vaccine. Years of occupational practice significantly influenced vaccination. While only 17.9% of HCWs who have worked in the hospital for 10 years or less were vaccinated, 41.79% of HCWs who have worked beyond 10 years were vaccinated. The most common reasons HCWs gave for not receiving HBV vaccination were lack of opportunity and unawareness/ignorance.[29] A cross-sectional survey carried out in Kaduna, North-western Nigeria among high-risk public safety workers (Federal Road Safety Corps [FRSC] members) found a high hepatitis B vaccine initiation rate (60.9%), with a low completion rate at 30.5%. The implication is that only 30.5% of members of the FRSC, in Kaunda State Command, were adequately protected against HBV infection. Nearly 27.6% of them had no risk perception for occupational exposure to HBV, whereas 72.4% perceived themselves at risk.[30] A cross-sectional study carried out at Lagos Island Maternity Hospital, in an urban community of Lagos state in Southwestern Nigeria, among HCWs found the prevalence of HBsAg as 1.5% among the respondents. This study, however, reported poor practice of vaccination against HBV infection among this group of HCWs in spite of good knowledge. In this study, less than half of the HCWs (48.5%) completed the three doses of HBV vaccine. About one-third (29%) of the respondents checked their immunity against hepatitis B after vaccination. In contrast, only 23.9% of the respondents found out they were protected after receiving the complete three doses of hepatitis B vaccine. Respondents' reasons for not being vaccinated included as follows: the vaccine was too expensive; vaccine was not available; fear that the vaccine hurts while some had no concrete reason.[31]

A hospital-based, cross-sectional study conducted among HCWs in UNTH, Enugu, South-eastern Nigeria revealed that the uptake of hepatitis B vaccination, as well as the number of doses received, was low among HCWs in Enugu, Nigeria. Age of HCW, staff category, and duration of work in the hospital were independently associated with HBV vaccination. This study also found that about half (48.9%) of those who were vaccinated received full coverage of the three doses of the HBV vaccine. The study findings also suggested that the common barriers for not getting vaccinated were the cost of vaccination, long vaccination schedule, not knowing where to take the vaccination, lack of time, and low-risk perception.[32] A study among HCWs in a teaching hospital in Ile-Ife, Nigeria, found that 65% of the health workers have been vaccinated against HBV before the study; however, the majority of nurses and pharmacists have never been screened for HBV infection.[33] This rate is higher than that from Sokoto, North-West Nigeria, where 56% of HCWs completed the recommended three doses of HBV vaccine.[34] Another study among operating room personnel across teaching hospitals in the various region of the country revealed that only 26.8% of this group of HCWs were vaccinated against HBV.[35] Similarly, the vaccination rate among laboratory workers in Warri Nigeria was as low as 16.4%.[36] In a study among dental surgeons in Benin, 31.4% were not vaccinated, 20% had completed three doses of the HBV vaccine, while 48.6% received either two doses or a single dose.[37] In general, most of the studies reviewed reported a low rate of HBV vaccine coverage among HCWs in Nigeria.[29],[30],[31],[32],[33],[34],[35],[36],[37] They also highlighted similar barriers to vaccination among HCWs across the various studies and regions, as shown in [Table 2].
Table 2: Barriers to vaccination of health-care workers for hepatitis B virus from studies in Nigeria

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  Discussion Top


Barriers to vaccination of health-care workers in Nigeria

Our findings suggest that in spite of the importance of vaccination in preventing the spread of infections in the health-care settings, vaccine uptake and vaccination coverage among HCWs in Nigeria remain suboptimal.[29],[30],[31],[32],[33],[34],[35],[36],[37] In spite of the availability of the vaccines, a large percentage of HCWs in the country are either unvaccinated or incompletely vaccinated with poor vaccine completion rates.[29],[30],[31],[32] Some possible explanations for this are the various barriers, especially, low-risk perception reported by various studies.[26],[27],[28] Motivation,[38] availability and access to vaccines, cost of vaccines, and long vaccine schedules are some of the other factors that have been suggested as determining the vaccine completion rates.[32],[39],[40] Although there appears to be a growing attempt at complying with the WHO recommendation on vaccination of HCWs, there are several challenges confronting this effort. One major challenge, for example, is whether there is a need for HBV vaccination among HCWs in a holoendemic country like Nigeria where there is a possibility of contracting the virus much earlier than starting work as HCWs. This factor in itself can influence policy decision and the readiness to establish and implement policies on HCWs vaccination. Another major challenge is a poor perception of the risk of contracting the disease, the higher the risk perception for occupational exposure to HBV, the higher the likely hood of getting vaccinated and vice versa. The low vaccination coverage rate to HBV vaccination among HCWs calls for concern among stakeholders, especially when the prevention of HBV infection among HCWs is through effective vaccination programs and adherence to universal safety precaution which most times cannot be guaranteed. There is a need for health education programs for HCWs enlightenment on hepatitis virus, mode of transmission, and the risks to which they are exposed at work, as the gap in the knowledge of risk perception is alarming. Knowledge is usually the first step toward the modification to desirable behavior, and therefore, enhancing knowledge will no doubt improve vaccine uptake and minimize this barrier and others. Our review also highlighted other major barriers to HCWs vaccination to include nonavailability of the vaccines, cost of vaccines, long vaccination schedules, poor awareness, busy schedules, fear of side effects, poor motivation, lack of explicit guidelines, and many more. Although this list is not exhaustive, the solution to these various challenges lies in having clear cut policy and guideline regarding HCWs vaccination. There is a necessity to improve the knowledge on vaccines, vaccination, and universal safety precaution; dousing fears about vaccination side effects and having a reminder system that can improve the vaccination completion rate among HCWs.

Policies and level of implementation

A sound policy is a deliberate system of principles that guide decision and achieve rational outcomes. Ineffective policy formulation and implementation are means by which a country can deplete its health workforce. HCWs vaccination policy in context, therefore, describes the plan for HCWs vaccination and specifies the framework that needs to be in place to achieve HCWs vaccination in the health-care setting. Having a policy with realistic implementation strategies, adequate funding and political will from the government will contribute immensely toward good vaccination uptake and coverage rates. The lack of vaccination policy explicit for HCWs in the country is a key factor militating against achieving a high coverage rate of vaccination among the HCWs. This lack of written policies on the vaccination of HCWs for health institution provides the opportunity for health authorities to be noncommittal in ensuring that HCWs are vaccinated. Health institution authorities, therefore, do not insist on the vaccination and completion of vaccination among HCWs. They also do not feel obliged to ensure preemployment HBV screening and vaccination among HCWs, thus, giving room for poor and in some instances nonimplementation of vaccination policies among HCWs. Owing to the high prevalence of HBV infection, a universal vaccination strategy is probably not enough to control the occupational risk of HBV among HCWs. The need to create and appropriately implement policies explicitly meant for HCWs vaccination cannot be overemphasized. Policies should extensively cover all means of protection of HCWs and the prevention of transmission of HBV and other vaccine-preventable diseases. The constitution of an appropriate implementation team that will ensure the vaccination of HCWs should be included in the written policy. The prevention of all forms of occupational risk exposures should be emphasized. Besides, the management of percutaneous or mucosal blood exposure and all forms of exposure should be ensured to prevent workplace outbreak.

Recommendations

In improving vaccination uptake and coverage among HCWs, there is a need for a clear policy on vaccination of HCWs in Nigeria. This policy should be designed to meet the need of HCWs and should be distinct from the general guideline on vaccination for the rest of the populace. It should incorporate model program options that can be adopted across health institutions at an affordable cost. Vaccination should be a preemployment requirement for all HCWs with participation made mandatory before their engagement. Training and awareness programs on vaccines and vaccination that encourage vaccination among HCWs should be developed. Comprehensive measures addressing all other forms of barriers to vaccination of HCWs such as cost, accessibility availability, and timing/schedule are required to ensure improved uptake and coverage. This program should also incorporate training of HCWs on infection control and universal Safety precaution. Regular, periodic programs must also be organized to further motivate and remind HCWs to complete their vaccination.

Study limitations

A limitation of this study was the variability within the studies on how some factors were defined and categorized (e.g., perception, vaccination status knowledge, etc.). However, this was minimized by aligning terminologies that were more consistent across the various studies.


  Conclusions Top


The article summarized the issues related to HCWs vaccination, the barriers, policy challenges, and level of implementation. It recommends model programs and policies that can be adopted by health authorities to address the various factors limiting vaccine uptake and coverage among HCWs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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