In 2009, the large gathering of the annual pilgrimage (known as the Hajj) occurred concomitantly with the swine flu pandemic and the global panic surrounding the possibility of a rapid outbreak. For these reasons, we were interested in studying high-risk participants who were assigned to provide services during the pilgrimage. This allowed us to gather information about their attitudes toward the H1N1 vaccine. We were also interested in identifying and assessing the short-term adverse effects of the newly manufactured vaccine . Regarding the current pandemic, the WHO had recommended that all countries give high priority to immunizing their HCWs to protect the essential health infrastructure. Despite these recommendations, the acceptance of voluntary vaccination was unexpectedly low .
This study explored reasons for swine flu vaccination refusal during a time of global public concern and anticipation of a global outbreak. In our cohort of Saudi National Guard employees assigned to work during the Hajj, 46.8% of participants accepted the vaccination. We found that more non-HCWs (mainly military personnel) accepted the vaccine than HCWs. This was consistent with our previously published finding that physicians had a low acceptance rate for both seasonal and pandemic vaccinations in early 2009/2010 .
Despite strong recommendations to vaccinate healthcare workers with the influenza vaccine, coverage was exceedingly low for all specialties, with some differences according to location and type of employment . In addition to education about preventive measures, such as frequent hand washing and wearing a mask, vaccination is an essential protective measure. Influenza vaccination among healthy working adults has been shown to be highly effective, resulting in a 25% reduction of upper respiratory illness . In this study, the reasons for refusal included worries about vaccination safety and doubts about vaccine efficacy. In a study from Hong Kong, the influenza vaccine was efficient in preventing H1N1 infection in 61% of the participants . In addition, some participants believed that other preventive measures could be applied to yield the same benefits; misleading information from the media may have been the source of this reasoning. One of the prominent sources of concern was the difference in chemical constituents between the vaccine used in developed countries and those used in developing countries including the Kingdom. Participants' hesitance, worry, and safety concerns about using a newly developed vaccine were other major determinants of negative response and vaccination refusal. The most common reasons for accepting the vaccination were a "wish to be protected" and "following health authority advice." The most common reason for refusal was "worry about side effects." In addition, some other reasons for refusing vaccination included "doubts about the efficacy of the vaccine," feeling that it was "not yet the right time to be vaccinated," and "simply not wanting the vaccine ." Vaccine-seeking consumers must first be convinced of a reasonable likelihood that the disease will occur in their location and that they are susceptible. Additionally, they must be convinced that the disease is serious. Finally, they must be convinced of the safety, if not the efficacy, of the vaccine before they will accept it . In a recent study conducted on a group of Saudi civilians, we were able to confirm that the media played a major role in decreasing the acceptance of the vaccine. Furthermore, the lack of public education by knowledgeable HCWs may have also contributed to popular belief in the negative propaganda . Campaigns and health education in advance to the next anticipated influenza outbreaks could play an essential role in encouraging communities to accept vaccinations during similar future circumstances.
Side effects experienced by the vaccinated individuals in the cohort consisted of normal short-term adverse effects . Therefore, the vaccine is promising for future use if any outbreak is expected, assuming that further assessment of the long-term adverse effects yields positive results.
Based on surveillance following the 1976 swine flu vaccination program, the risk of anaphylaxis from the influenza vaccination was estimated to be approximately one in every four million people. In 1976, Guillain-Barré syndrome was associated with receipt of the swine flu vaccine, with a risk of 1 per 100,000 individuals vaccinated . Safety and efficacy are critical factors in determining the rate of vaccination in the general population. Governments that want to promote H1N1 vaccination will need to gain a better understanding of the barriers to and facilitators of acceptability before implementing full-scale vaccination programs .
The current study demonstrated a substantial increase in participant awareness. Most participants understood that applying as many protective measures as possible allows for the best protection from swine flu infection. Our results also suggest that frequent hand washing is seen as one of the most influential protective measure. When participants were asked about future vaccines three weeks after the vaccination campaign, an increased number of participants (11 out of 67) had changed their minds and would accept vaccination in the future. This change of opinion among the participants could contribute to a higher acceptance rate if vaccinations are offered during future pandemics. The presence of participants in the same campus for three weeks post-vaccination, coupled with an exchange of information between the accepting and refusing groups, may have been the reasons that some participants changed their willingness to receive a future vaccination. HCWs were seriously deficient in terms of their knowledge of influenza prevention. Extensive and sustained efforts to overcome these limitations are urgently needed among HCWs, regardless of whether they are involved in direct or indirect patient care . These efforts will help to increase effective compliance among HCWs and the general public.