Open Access Highly Accessed Research article

Attitudes of healthcare workers in U.S. hospitals regarding smallpox vaccination

W Katherine Yih1*, Tracy A Lieu123, Virginia H Rêgo1, Megan A O'Brien1, David K Shay4, Deborah S Yokoe56 and Richard Platt1567

Author Affiliations

1 Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA

2 Center for Child Health Care Studies, Harvard Pilgrim Health Care, Boston, MA, USA

3 Division of General Pediatrics, Children's Hospital Boston, USA

4 Immunization Safety Branch, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA, USA

5 Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

6 CDC Eastern Massachusetts Prevention Epicenter, USA

7 HMO Research Network Center for Education and Research in Therapeutics, USA

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BMC Public Health 2003, 3:20  doi:10.1186/1471-2458-3-20

Published: 11 June 2003



The United States is implementing plans to immunize 500,000 hospital-based healthcare workers against smallpox. Vaccination is voluntary, and it is unknown what factors drive vaccine acceptance. This study's aims were to estimate the proportion of workers willing to accept vaccination and to identify factors likely to influence their decisions.


The survey was conducted among physicians, nurses, and others working primarily in emergency departments or intensive care units at 21 acute-care hospitals in 10 states during the two weeks before the U.S. national immunization program for healthcare workers was announced in December 2002. Of the questionnaires distributed, 1,165 were returned, for a response rate of 81%. The data were analyzed by logistic regression and were adjusted for clustering within hospital and for different number of responses per hospital, using generalized linear mixed models and SAS's NLMIXED procedure.


Sixty-one percent of respondents said they would definitely or probably be vaccinated, while 39% were undecided or inclined against it. Fifty-three percent rated the risk of a bioterrorist attack using smallpox in the United States in the next two years as either intermediate or high. Forty-seven percent did not feel well-informed about the risks and benefits of vaccination. Principal concerns were adverse reactions and the risk of transmitting vaccinia. In multivariate analysis, four variables were associated with willingness to be vaccinated: perceived risk of an attack, self-assessed knowledge about smallpox vaccination, self-assessed previous smallpox vaccination status, and gender.


The success of smallpox vaccination efforts will ultimately depend on the relative weight in people's minds of the risk of vaccine adverse events compared with the risk of being exposed to the disease. Although more than half of the respondents thought the likelihood of a bioterrorist smallpox attack was intermediate or high, less than 10% of the group slated for vaccination has actually accepted it at this time. Unless new information about the threat of a smallpox attack becomes available, healthcare workers' perceptions of the vaccine's risks will likely continue to drive their ongoing decisions about smallpox vaccination.