C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY
RESEARCH PAPER

Uptake of influenza vaccination and risk reduction behaviour for

respiratory infections: a survey of optometrists in New Zealand

Clin Exp Optom 2014; 97: 418421 DOI:10.1111/cxo.12149

Albert Vosseler* MBChB Background: The aim was to determine the uptake of seasonal influenza vaccination
Graham A Wilson MBChB FRANZCO and risk reduction behaviours among a health professional group with close patient contact,
MOphth namely, optometrists. This group can have close facial proximity to patients during eye
Nick Wilson MBChB MPH examinations.
* Department of Ophthalmology, Capital and Coast Methods: National telephone survey of optometrists in New Zealand.
DHB, Wellington, New Zealand Results: Seventy per cent of registered optometrists participated (n = 450 responses). Less

Department of Ophthalmology, Tairawhiti District

than one-third (29.7 per cent, 95% CI: 27.4 to 32.0) of optometrists reported having had the
Health, Gisborne, New Zealand

Department of Public Health, University of Otago,
Wellington, New Zealand
E-mail: Albie.Vosseler@ccdhb.org.nz
Submitted: 21 April 2013
Revised: 11 February 2014
Accepted for publication: 17 February 2014
seasonal influenza vaccination in 2012. The major reason given for not being vaccinated was
that the vaccination was considered unnecessary (47 per cent) followed by time constraints
(28 per cent). During their last respiratory illness, 82 per cent reported working with
symptoms and only 16 per cent reported the use of a face mask.
Conclusion: There is major scope for increasing uptake of influenza vaccination and other
protective behaviour for such health professional groups, especially those characterised
by relatively close patient contact. Possible options include educational campaigns and
government-funded vaccinators visiting the workplaces of all health-care workers.

Key words: facemask, influenza, optometrist, symptomatic, vaccination

Health authorities generally recommend
that health-care workers (HCWs) are vacci-
nated annually against influenza so as to
protect patients and themselves.1 Seasonal
influenza vaccination reduces the rate of
seroconversion among HCWs by 88 per cent
(reflecting a reduction in both symptoma-
tic and asymptomatic infection).2 Further-
more, some authors argue that HCWs have
a particular ethical imperative to protect
patients from influenza and even consider
that vaccination of all HCWs should be com-
pulsory.3 Not only do HCWs who receive an
influenza vaccination have a lower risk of
infection, they potentially reduce the infec-
tion rate and mortality of patients under
their care, particularly the elderly and
immunocompromised, who are most vulner-
able (although the evidence for patient pro-
tection is only moderate and more studies
are required).2,4,5
Another issue of relevance to health
authorities is that influenza vaccination of
healthy adults has been shown to reduce
(albeit by a modest amount) days off work in
a systematic review.6 This benefit could be
especially relevant for maximising the capac-
ity of the health-care workforce during high
work-demand winter periods.
Unfortunately, the uptake of influenza
vaccination among HCWs in most countries
is far from optimal. For example, the cover-
age is under 50 per cent in New Zealand
despite programs to promote it, while in
the US, rates remain less than 40 per cent.7,8
Furthermore, HCWs often present to work
while unwell with respiratory or viral ill-
nesses, thus highlighting the need for addi-
tional behavioural changes, such as staying
at home while symptomatic.2,9
To further study these issues, we consid-
ered a health professional group that has
relatively close patient contact, namely,
optometrists. These HCWs are close to pati-
ents during eye examinations and may also
touch the face and eyelids of patients (for
example, when administering eye drops).
Another reason to study this population is
that they are generally self-employed and
therefore, this would provide information
on HCWs who are outside of large institu-
tions, such as hospitals (some of which offer
fully subsidised influenza vaccinations to
their staff). The primary aims of this study
were to determine the uptake of seasonal
influenza vaccination and reasons for no
uptake among a health-professional group
with close patient contact, namely, optom-
etrists. We hypothesised that both vaccina-
tion uptake and risk reduction behaviour
would be suboptimal given the existing
literature relating to health professionals in
general.
A secondary aim was to identify risk reduc-
tion behaviour in this group. The rationale
for the secondary aim is that such behaviour
is also desirable regardless of influenza vac-
cination given that influenza vaccination is
not always effective and because other (non-
influenza) respiratory infections can also be
transmitted from infected HCWs to patients.
METHODS
Contact details for New Zealand optom-
etrists were collected from a voluntary on-
line membership list that comprises 94 per
cent of New Zealand optometrists (http://
www.nzao.co.nz/locate-an-optometrist).
Those listed were then telephoned by one of

Clinical and Experimental Optometry 97.5 September 2014 2014 The Authors
418 Clinical and Experimental Optometry 2014 Optometrists Association Australia

Primary barrier reported
Did not feel it is necessary
Time constraints
Did not feel it is effective
Medical reason (contraindication, allergy or other)
Cost of vaccination
Other*
Total
*Other: Needle phobic (n = 5), concerned by possible adverse effects (n = 6), opposed to
vaccination (n = 2), other not further defined (n = 7)
Table 1. Primary barriers to influenza vaccination reported by those optometrists not
being vaccinated in 2012 (n = 316)
the authors (AV) during November 2012
and asked for consent to participate in a
telephone survey.
Data were collected from the interviewees
on their self-reported influenza vaccination
status during the year 2012 and whether this
vaccination was provided in a general prac-
tice setting or elsewhere. If no vaccination
had been administered, the participant was
questioned on the main reason for having
not received one and asked to choose from
one of the six options read out, as outlined
in Table 1. Information was also collected
from a subset of the respondents regarding
work attendance while having respiratory
symptoms (cough, runny nose, sore throat,
myalgia or fever) during their most recent
acute respiratory illness. This subset arose
when an extra question was included in the
study, part way through. As a consequence,
96 participants who had been interviewed
were not included in the analysis of this
work attendance while ill question. These
excluded participants were almost exclu-
sively from the Northland and Auckland
regions. Practices located in cities (popula-
tion greater than 50,000) were compared
with smaller urban areas (less than 50,000)
as per the official classification by Statis-
tics New Zealand. Data were stored using
Microsoft Excel software and analysed using
the online epidemiology software OpenEpi
(http://www.openepi.com). Confidence
intervals for binomal data were calculated
using a Wilson score. The two-tailed mid-P
exact test was used to test for statistical
significance between vaccinated and unvac-
cinated subgroups.
Ethics approval for this study was sought
through the Health and Disability Ethics
2014 The Authors
Clinical and Experimental Optometry 2014 Optometrists Association Australia
Uptake of influenza vaccination and risk reduction behaviour Vosseler, Wilson and Wilson
n % (95% CI)
148 46.8 (42.950.7)
89 28.2 (24.631.8)
39 12.3 (9.714.9)
15 4.7 (3.06.4)
5 1.6 (0.62.6)
20 6.3 (4.48.2)
316 100%
Committee of New Zealand (HDEC); how-
ever, the study was deemed to not require
formal ethical approval (being a low-risk
retrospective observational study with no
patient involvement).
RESULTS
According to the Optometrists and Dispens-
ing Opticians Board of New Zealand, there
were 645 optometrists holding a current
practising certificate in 2012. We were able
to gather the contact details of 528 optom-
etrists from online sources. Those remain-
ing were either not listed with the New
Zealand Association of Optometrists or they
did not have their contact details published
(for example, they may primarily do locum
work). Of the 528 optometrists we attempted
to contact, 33 (6.3 per cent) refused to par-
ticipate and another 45 (8.5 per cent) were
non-contactable. This left a total of 450
optometrists who were interviewed, which
represents 70 per cent of the currently reg-
istered population.
Less than a third of optometrists inter-
viewed had received an influenza vaccina-
tion in 2012, at 134 (29.7 per cent, 95% CI:
25.7 to 34.2). Most received it from their
general practice (91.0 per cent, n = 122), 4.5
per cent (n = 6) received it at their work
place from either a nurse in the practice
or a visiting nurse and 3.7 per cent (n = 5)
received the vaccination from a hospital as a
place of work. No statistically significant dif-
ference was noted in rates between those
working in cities at 29.6 per cent (104/351)
versus exclusively small urban areas at 30.3
per cent (30/99) (p = 0.89).
Clinical and Experimental Optometry 97.5 September 2014
Of those who did not receive a vaccina-
tion, slightly under half (46.8 per cent, n =
148) reported (as their primary reason) that
they did not consider it necessary. The next
most common reason was time constraints
(28.2 per cent, n = 89), followed by concerns
with the efficacy of the vaccination, at 12.3
per cent (n = 39) (Table 1).
Of the optometrists surveyed regarding
work attendance, around two-thirds (67.3
per cent, 303/354) could remember their
most recent respiratory illness. Of these,
under a fifth (17.8 per cent, n = 54) stayed at
home until asymptomatic. The largest pro-
portion worked through the period of their
illness (41.6 per cent, n = 126), followed by a
quarter (24.4 per cent, n = 74) who returned
to work with respiratory or systemic symp-
toms still present (Table 2). The majority
(82.2 per cent, n = 249) of those surveyed
reported working while symptomatic and
only 16.2 per cent (n = 49) reported wearing
a face mask while at work.
DISCUSSION
Main findings and interpretation
The low level of uptake of seasonal influenza
vaccination among these HCWs is in keep-
ing with the low levels among other HCWs,
both domestically7 and internationally.8,10,11
In the context of having to pay for and seek
out the vaccination, it is not surprising that
the level of vaccination is less than levels
reported for HCWs in publicly funded
health settings in New Zealand (range 57 per
cent for doctors to 37 per cent for mid-
wives).7 The primary reason for not being
vaccinated was a belief that vaccination was
not necessary, due to a perception of low
personal risk of infection, a view that is
common among HCWs.12 While concerns
with adverse effects from vaccination were
not directly addressed, these are generally
minimal or very rare, that is, vaccination may
cause discomfort at the site of injection and
systemic myalgia; however, no other systemic
effects are significantly associated with the
vaccination.6
The high proportion (82.2 per cent) of
these HCWs who continued to work with
acute respiratory symptoms during their last
illness is also problematic from a patient
protection perspective. Yet even if HCWs
never worked with such symptoms, infec-
tion could still be spread by them given
that viral shedding can begin prior to the
419
Uptake of influenza vaccination and risk reduction behaviour Vosseler, Wilson and Wilson

Reported behaviour
Took time off work and returned to work when symptom-free
Took time off work but returned to work with symptoms remaining
and did not use a face mask
Continued to attend work and did not use a face mask
Continued to attend work or returned to work with symptoms and
wore a face mask at work
Total
Table 2. Work attendance and mask wearing during the most recent respiratory illness
reported by the optometrists surveyed (of those who could remember such an illness,
that is, n = 303)
development of symptoms of influenza13 and
that sub-clinical infection also occurs (for
example, one study found more than 25 per
cent of all influenza infections in hospital-
based HCWs to be sub-clinical).14
A minority of the optometrists who
worked while symptomatic wore surgical
face masks while in contact with patients
(16.2 per cent). This may be worthwhile, as
there is some evidence for these masks
decreasing the risk of transmission from
the symptomatic mask wearer to others,1518
although further research on the matter is
desirable.
Strengths and limitations
This study was able to achieve a relatively
high rate of participation (at 70 per cent) for
a survey of busy health professionals who are
largely in private practice. Nevertheless, it
potentially suffers from limitations of all
such surveys in terms of potential recall bias
and social desirability bias. If the latter were
important, it may suggest that true vaccina-
tion uptake is even lower, and working while
symptomatic is even higher than the figures
reported here. Additionally, the inclusion
of an additional question part-way through
the survey (on work attendance when ill)
resulted in this information being limited to
optometrists working outside the Auckland
and Northland regions of the country.
Should significant regional differences in
work place practices exist throughout New
Zealand, such as greater availability of locum
optometrists in cities, time pressures, or solo
practioners in smaller centres, the result for
this aspect may not accurately represent the
population of optometrists in the country as
a whole.
n % (95% CI)
54 17.8 (14.720.9)
74 24.4 (20.927.9)
126 41.6 (37.645.6)
49 16.2 (13.219.2)
303 100%
Implications for research
and policymaking
If the government and health-professional
bodies wish to maximise patient protection
from influenza and also maximise worker
health, then more needs to be done to
enhance HCW uptake of seasonal influenza
vaccinations. While compulsory vaccination
is an option (for example, for HCWs without
medical grounds against it), this may engen-
der too much resistance from HCWs in
many settings.19 More realistic options may
be educational campaigns to enhance HCW
awareness of the risks of influenza, their
ethical obligations to maximise patient
protection, the potential benefit to them-
selves and to preserving health sector capac-
ity during winter from reducing sickness
absenteeism.12,20,21
To further facilitate vaccination uptake,
more could be done to make vaccination an
easier option for busy HCWs. For example,
public health nurse vaccinators could have
government funding to visit and vaccinate
HCWs in their private practices.22 Also all
HCWs could be provided with access to
fully subsidised vaccinations (for example,
as used for certain risk groups in various
countries).
The issue of working with respiratory
symptoms is complex and could benefit
from further research, especially among
private sector HCWs (who face significant
financial pressures, if they are sole operators
or business owners). While it may seem
optimal to never work with such symptoms, it
would be useful to have more research evi-
dence around the benefits of the alternatives
of rigorous respiratory hygiene (including
use of face masks), in addition to rigorous
hand hygiene.
ACKNOWLEDGEMENTS
The authors thank the participating optom-
etrists for their time and assistance.
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