Corresponding author: Kuo-Chin Huang, MD, PhD, Department of Family Medicine, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei, Taiwan. E-mail: firstname.lastname@example.org
College freshmen living in dormitories are at increased risk for meningococcal disease. Many students become a high-risk population when they travel to the United States. This study surveyed the knowledge, attitudes toward, and behavior surrounding the disease among Taiwanese college students planning to study in the United States, and to identify factors that may affect willingness to accept meningococcal vaccination.
A cross-sectional survey of college students going to study in the United States was conducted in a medical center-based travel medicine clinic. Background information, attitudes, general knowledge, preventive or postexposure management, and individual preventive practices were collected through a structured questionnaire.
A total of 358 students were included in the final analysis. More than 90% of participants believed that preventing meningococcal disease was important. However, fewer than 50% of students accurately answered six of nine questions exploring knowledge of the disease, and only 17.3% of students knew the correct management strategy after close contact with patients. Logistic regression analysis showed that students who understood the mode of transmission (odds ratio: 3.21, 95% CI = 1.117–9.229), medication management (1.88, 1.045–3.38), and epidemiology (2.735, 1.478–5.061) tended to be vaccinated.
Despite an overall positive attitude toward meningococcal vaccination, there was poor knowledge about meningococcal disease. Promoting education on the mode of transmission, epidemiology, and pharmacological management of the disease could increase vaccination rates. Both the governments and travel medicine specialists should work together on developing an education program for this high-risk group other than just requiring vaccination.
Despite advances in global efforts to develop new vaccines, invasive meningococcal disease remains a devastating disease with a fulminant course.[1-8] The annual incidence was 0.33 cases per 100,000 population in 2007 and an estimated 1,525 cases of meningococcal disease occur annually in the United States. Because the incidence is highest among infants and adolescents, routine immunization from the ages of 11 to 19 years (especially between the ages of 11 and 12 years) is recommended by the Advisory Committee on Immunization Practices.[10-12]
College freshmen living in dormitories are at particularly high risk for developing meningococcal disease. Because of this, students from overseas who are planning to live in college dormitories are usually required to provide proof of meningococcal immunization in the United States and other countries such as the United Kingdom. Many Taiwanese students preparing to study in the United States are required to have the vaccination, which is not a routine immunization in Taiwan. In addition, the vaccine is available only at 12 Centers for Disease Control contracted hospitals due to the scarceness of the vaccine in Taiwan.
However, receiving vaccination without learning about the disease is not enough to assure prevention and patient-level factors may influence immunization coverage. Furthermore, educating patients about the risk of contracting the disease and the importance of the vaccine should be an essential part of the physician–patient discussion about vaccination.
Thus far, few studies have investigated the awareness and attitudes toward meningococcal disease among high-risk students. We designed a study to survey the knowledge, attitudes, and behaviors about the disease among Taiwanese students planning to study in the United States.
Study Design and Participants
A cross-sectional questionnaire survey on Taiwanese college students planning to study in the United States was conducted in National Taiwan University Hospital in Taipei, a medical center-based travel medicine clinic, from January 2009 to December 2010. The questionnaire and consent forms were distributed to all college-age nonmedical students from different universities planning to study in the United States. All study procedures were approved by the ethical committee of the National Taiwan University Hospital.
A self-administered, single-choice questionnaire surveyed the background information, attitudes toward, and knowledge about meningococcal disease. The questionnaire was based upon personal practice experiences and designed after a careful literature review. Excluding background information, the questionnaire included two questions about attitudes, five questions about general knowledge of the disease, four questions on preventive or postexposure management, and two questions on individual preventive practices. Five experts tested the content validity, while the face validity was tested by five college students.
Data management and statistical analyses were performed using SPSS 11.0 software. Frequency distributions were used to describe the demographic data. Stepwise logistic regression analysis determined the relative values of the variables related to positive attitudes on receiving vaccines and willingness to perform individual preventive practices. A p-value less than 0.05 was considered statistically significant.
Questionnaires were given to 450 students, and complete information was collected from 358 (154 males and 204 females) after eliminating incomplete questionnaires (effective response rate: 80%). The mean age of the final study group was 24.9 years.
Attitudes and Individual Preventive Practices
Among the 358 students included in the analysis, 93% had prior knowledge of meningococcal disease; however, only 49.4% were aware there was a vaccine for the disease. Ninety-six percent of students considered vaccination to be important and 91.3% thought receiving vaccination was reasonable when visiting an area where vaccination was recommended but not required. Although insurance does not cover the cost of meningococcal vaccination in Taiwan (the mean meningo vaccination price is 24.97 USD), 86.3% of students indicated that they would pay for vaccination, even if the vaccination were recommended but not required (Table 1).
Table 1. Demographic data, attitude, and practice survey
Age (average = 24.88 years ; SD = 5.32)
Has heard of meningitis?
Has heard of meningococcal vaccines?
Important to receive vaccines if required
Important to receive vaccines if it is just recommended
Cash for the vaccine if it is just recommended
Will you seek more information on this issue?
General Knowledge of Meningococcal Disease
On two questions about general knowledge of meningococcal disease, fewer than 50% of students answered correctly (Figure 1). For example, only 31.3% of students knew how the disease was transmitted, although approximately 70% were aware of the common symptoms of meningococcal diseases.
Preventive or Postexposure Management Knowledge
Figure 2 shows the items surveyed and percentages of accurate responses about preventive or postexposure management of meningococcal disease. Fewer than half of students could accurately answer all four questions about how the disease was managed, such as timing of the first vaccination or medical management. For one item, management after close contact, only 17.3% of the students responded correctly.
Important Predictive Variables of the Positive Attitudes and Preventive Practices
Results of stepwise logistic regression analysis revealed three statistically significant predicting variables on positive attitudes and willingness of receiving vaccination by cash (Table 2). The analysis showed that students had positive attitudes toward vaccines and were willing to receive vaccination if they understood the mode of transmission (odds ratio: 3.21, 95% CI = 1.117–9.229), medication management (1.88, 1.045–3.38), and epidemiology (2.735, 1.478–5.061).
Table 2. Significant predictive knowledge questionnaire items related to the attitude toward meningococcal vaccine
95% CI of OR
β = normalized beta coefficient; SE = standard error; OR = odds ratio; CI = confidence interval.
Important to receive the vaccine if it is only recommended
Cash for the vaccine if it is just recommended
To our knowledge, this is one of the first studies to investigate the knowledge and attitudes and practices toward meningococcal disease in a high-risk group, and to explore factors that might increase the acceptance of vaccination. Furthermore, the students' poor knowledge of the disease but strongly positive beliefs toward the vaccine is a good indication that better education for this high-risk group and efforts at prevention are worthwhile goals for the government and medical personnel.
The World Health Organization and the US Centers for Disease Control and Prevention recommend prompt antibiotic prophylaxis for persons with close contact with invasive meningococcal disease patients, but only 17.3% of students in this study understood this. This effective way to prevent further transmission of invasive meningococcal disease may become impossible under these circumstances. Poor knowledge of the disease, which threatens disease prevention, was also demonstrated by questions about the timing of the initial vaccination, or the time needed for antibody to develop after vaccination. If students believe they are protected quickly after vaccination, many could arrive at the United States with insufficient immunity against meningococcal disease, despite the fact that they had been vaccinated. Moreover, only about 30% of students understood the “transmission mode” and “infectious agents” of meningococcal disease. This lack of basic knowledge of meningococcal disease indicates that students are neither being alerted to the disease nor having enough information about when becoming a high-risk group.
Increasing vaccination coverage is essential for effective infectious disease control, and understanding the patient factors influencing acceptance of vaccination would help both the government and medical professionals develop and institute strategies for disease prevention. The study demonstrated that knowledge of meningococcal disease, including transmission mode, epidemiology, and medication management, were independent factors that influenced willingness to be vaccinated against the disease. Thus, we should put more emphasis on these issues in public health programs or individual education courses. Moreover, previous similar study results helped Taiwan Centers for Disease Control design continuing education programs on dengue fever, yellow fever, and malaria prevention for health professionals. The results of this study might also provide a focus for training medical personnel and stimulate discussion of meningococcal disease prevention in travel medicine clinics.
There are some limitations to this study. First, the financial factors surrounding the vaccine, especially the cost, may affect willingness to be vaccinated, a factor that is not disclosed on the questionnaire. Second, only 80% of the students surveyed returned the completed questionnaires, and distributing the questionnaire to the students in a busy clinic setting might have influenced this effective response rate. Third, because the study was a cross-sectional survey, designing a future follow-up study that could show the effects of education about the disease and vaccination is strongly suggested. Fourth, since individual countries have their own unique disease epidemiology, vaccine strategies, and macro socioeconomic status, certain results of this study might need to be modified.
Enhancing education and knowledge of the public and health professionals is crucial for controlling vaccine-preventable disease. Our study results showed that despite an overall positive attitude toward meningococcal vaccination, there was poor knowledge about meningococcal disease. Promoting education about the disease, especially the mode of transmission, along with the epidemiology and medical management of the disease, could increase vaccination rates and reduce risk. This kind of survey should be adopted in other countries, and certain results could provide new insights for disease prevention and future research focus. Both the governments and travel medicine specialists should work together on developing an education program for this high-risk group other than just requiring vaccination.
We would like to thank Miss Chia-Chi Yu for her assistance in this study. We also thank the Centers for Disease Control, Taiwan for kind research support (LA099077-1).
Declaration of Interests
The authors state they have no conflicts of interest to declare.