Keywords
Blood transfusion - cirrhosis - jaundice - liver cancer - vaccination
INTRODUCTION
Hepatitis B virus (HBV) infection is a major global health problem affecting large
number of people every year.[1] HBV primarily targets liver and can cause both acute and chronic liver disease.
HBV infection is asymptomatic in majority of the people and the chronic infection
may lead to serious complications such as cirrhosis of the liver and hepatocellular
carcinoma.[2],[3],[4] As per the latest World Health Organization (WHO) report, dated July 18, 2018: globally,
by the end of 2015, an estimated 257 million people were living with HBV,[5] and approximately 887,000 deaths[5] have occurred, largely because of chronic complications of HBV infection such as
hepatic cirrhosis and liver cancer. The virus transmits through blood and other body
fluids from the infected persons. Use of contaminated needles for injections, blood
transfusion, sexual contact, and vertical transmission from mother to fetus are the
most common routes of transmission.[6],[7],[8],[9] HBV infection is an occupational hazard and the risk in health-care professionals
is 2–10 times higher than the general population.[10],[11],[12] Health-care workers and medical students in clinical years, who come in contact
with the patients and their potentially infectious materials such as blood and other
body fluids, are at highest risk of acquiring the infection and should be protected.[13] Medical students form the integral part of health-care system and they must have
a proper knowledge about hepatitis B infection, modes of transmission, clinical features,
complications, and preventive measures. The proper knowledge helps them to take necessary
precautions to prevent the disease and also to spread awareness about hepatitis B
infection among public, patients, and other health-care professionals.[14]
Vaccination and the use of personal protective equipment are the two major weapons
for the prevention of hepatitis B infection. Recombinant hepatitis B vaccine, which
is licensed for use, is advised for all health-care workers and medical students.[15],[16],[17],[18],[19] Three doses of vaccine at 0, 1, and 6–12 months are recommended for optimum protection.
This research was intended to assess the knowledge and awareness regarding hepatitis
B among preclinical year students (fourth and fifth-year medical students) of College
of Medicine and Health Sciences (CMHS), National University of Science and Technology
(NUST), Oman, Sultanate of Oman.
MATERIALS AND METHODS
Study design: It was a descriptive cross-sectional study conducted at CMHS during the academic
year 2017–2018. The study group included all the preclinical year students (year 4
and year 5). The study was approved by the Institutional Research and Ethics Committee,
and it was conducted after obtaining necessary informed consent from the students.
A notice regarding the study was circulated to all the preclinical year students through
proper channels of the Microbiology and Immunology department, and all efforts were
made to make them participate in the study voluntarily. A predesigned self-administered
questionnaire confined to knowledge and awareness regarding hepatitis B, its modes
of transmission and prevention, and their vaccination status was prepared in a Microsoft
Word document and distributed in a lecture hall to all the participants on a prenotified
date and time. The data were collected, tabulated, and statistically analyzed using
Microsoft Excel and Statistical Package for the Social Sciences (SPSS) software, version
22. IBM Chicago. Quantitative data were expressed in numbers and percentages.
RESULTS AND ANALYSIS
A total of 132 students voluntarily participated in the study. Data regarding knowledge
and awareness of hepatitis B among students of preclinical years is described in [Table 1], [Table 2], [Table 3], [Table 4]. The data reveal that majority (84.8%) of students were aware of hepatitis B and
77.3% believed that it is an infectious disease. Among the participants, 71.2% knew
that hepatitis B is caused by a virus and approximately 70.5% of the participants
stated that doctors and medical students are at risk of acquiring hepatitis B from
the infected patients.{Table 1}{Table 2}{Table 3}{Table 4}
Table 1
Statements regarding basic knowledge about hepatitis B
|
Statement
|
Students’ responses (n = 132)
|
|
Yes
|
No
|
Do not know
|
|
Have you heard about hepatitis B infection?
|
112 (84.8%)
|
20 (15.2%)
|
-
|
|
Is hepatitis B an infectious disease?
|
102 (77.3%)
|
18 (13.6%)
|
12 (9.1%)
|
|
What is the causative agent of hepatitis B?
|
Virus, 94 (71.2%)
|
Bacteria, 35 (26.5%)
|
Parasite, 3 (2.3%)
|
|
Do you think doctors and medical students are at risk of acquiring hepatitis B infection
from the patients?
|
93 (70.5%)
|
24 (18.2%)
|
15 (11.36%)
|
Table 2
Statements regarding awareness of transmission of hepatitis B infection
|
Statement
|
Students’ responses (n = 132)
|
|
Yes
|
No
|
|
PET – Positron emission tomography
|
|
Blood transfusion
|
107 (81.1%)
|
25 (18.9%)
|
|
Use of contaminated syringes and needles
|
98 (74.2%)
|
34 (25.8%)
|
|
Sexual contact with infected person
|
38 (28.8%)
|
94 (71.2%)
|
|
Vertical transmission (from mother to fetus)
|
31 (23.5%)
|
101 (76.5%)
|
|
Piercing and tattoo
|
41 (31.1%)
|
91 (68.9%)
|
|
Consumption of contaminated food and water
|
37 (28.0%)
|
95 (72.0%)
|
Table 3
Statements regarding awareness of clinical signs and symptoms of hepatitis B
|
Statement
|
Students’ responses (n = 132)
|
|
Yes
|
No
|
|
What are the signs and symptoms that can be seen in acute hepatitis B infection?
|
56 (42.4%)
|
76 (57.6%)
|
|
Fever: 56 (42.42%)
|
34 (25.8%)
|
98 (74.2%)
|
|
Loss of appetite: 34 (25.76%)
|
37 (28.0%)
|
95 (72.0%)
|
|
Nausea and vomiting: 37 (28.03%)
|
96 (72.7%)
|
36 (27.3%)
|
|
Jaundice: 96 (72.72%)
|
107 (81.1%)
|
25 (18.9%)
|
|
Most of the patients with chronic hepatitis B infection are symptomatic:
|
65 (49.2%)
|
67 (50.8%)
|
|
Do you think chronic hepatitis B infection can lead to cirrhosis of the liver?
|
34 (25.8%)
|
98 (74.24%)
|
|
Do you think chronic hepatitis B infection can lead to liver cancer?
|
56 (42.4%)
|
76 (57.6%)
|
Table 4
Statements regarding prevention of hepatitis B infection and vaccination status
|
Statement
|
Students’ responses
|
|
Yes
|
No
|
Do not know
|
|
Is hepatitis B infection preventable?
|
107 (81.1%)
|
6 (4.5%)
|
19 (14.4%)
|
|
Which of the following is/are preventive measures for hepatitis B infection?
|
|
Wearing gloves, caps, masks, gowns, and goggles
|
71 (53.8%)
|
21 (15.9%)
|
40 (30.3%)
|
|
Proper cooking of food
|
34 (25.76%)
|
56 (42.4%)
|
32 (24.2%)
|
|
Vaccination
|
96 (72.72%)
|
6 (4.5%)
|
30 (22.7%)
|
|
Use of sterile needles and syringes
|
98 (74.24%)
|
15 (11.4%)
|
19 (14.4%)
|
|
Screening blood donor
|
107 (81.06%)
|
5 (3.8%)
|
20 (15.1%)
|
|
Have you ever been vaccinated against hepatitis B?
|
53 (40.15%)
|
19 (14.39%)
|
60 (45.45%)
|
|
If yes, how many doses of vaccine have you taken?
|
|
One dose
|
13 (9.85%)
|
-
|
-
|
|
Two doses
|
9 (6.82%)
|
-
|
-
|
|
Three doses
|
31 (23.48%)
|
-
|
-
|
Regarding the modes of transmission of hepatitis B infection, 81.06% and 74.1% of
the students had a correct knowledge that it is transmitted through blood transfusion
and by the use of contaminated syringes and needles, respectively. The knowledge of
the students about other modes of transmission such as sexual contact (28.8%), mother
to baby (23.5%), and piercing and tattoo (31.1%) was weak. Twenty-eight percent of
the students incorrectly stated that it can be transmitted through contaminated food
and water, though hepatitis B is not a food and waterborne disease.
The clinical features of acute hepatitis B infection are not well understood by majority
of the students. Approximately, three-fourth of students (72.7%) knew that it can
cause jaundice. However, their knowledge about other clinical manifestations such
as fever (42.4%), loss of appetite (25.8%), and nausea and vomiting (28.0%) is poor.
In addition, 81.1% of the students did not know that hepatitis B infection is often
asymptomatic in majority of the patients. The students’ knowledge about chronic complications
associated with hepatitis B infection is also poor as only 49.2% and 25.8% of the
students correctly stated that cirrhosis of the liver and liver cancer, respectively,
are the common associated complications.
Approximately four-fifth of the students (81.1%) knew that hepatitis B is a preventable
disease. Most of the students have well understood that screening of blood donors
(81.1%), vaccination (72.7%), and use of sterile needles and syringes (74.2%) are
important preventive measures. The use of personal protective equipment, such as gloves,
caps, masks, and gowns, as preventive measure was indicated only by 53.8% of the students.
Less than half of the participants (40.2%) stated they had taken vaccine. Of that,
only 31 (23.5%) students stated that they are fully immunized with three doses of
vaccine.
DISCUSSION
Exposure to blood-borne pathogens, such as HBV and human immunodeficiency virus, constitutes
a significant occupational health hazard to health-care professionals.[20] The knowledge, attitude, and practice (KAP) surveys are important tools to identify
the problems, recommend solutions, and implement policies.[20] The data of KAP surveys on hepatitis B among medical students in this part of Oman
are unavailable, and hence this study was sought to assess the knowledge and awareness
about hepatitis B among preclinical year students of CMHS. The results of our study
warrant health awareness and vaccination drive to protect future budding doctors against
HBV infection to which they are likely to encounter in their medical career.[21]
CMHS follows a 7-year medical degree program and the curriculum includes foundation,
premed, preclinical, and clinical courses. During premed and preclinical years, students
learn about basic sciences before they enter into clinical years where they study
clinical subjects and approach patients.
The WHO has set a goal to eliminate viral hepatitis by 2030, and the lack of general
knowledge and awareness about HBV infection seems to be a hurdle for achieving this
goal.[22] The overall knowledge about HBV, its modes of transmission, and prevention is deficient
among our study participants, but it is acceptable for the preclinical students as
they are in the beginning of their medical course. However, a scientific and precise
knowledge about HBV is highly essential for a medical student as it transmits 2–10
times higher in medical professionals.[9],[10] In this study, it was good to observe that majority of the respondents were aware
of hepatitis B (84.8%) and its causative agent (71.2%), which is in line with the
results of similar other studies.[23],[24],[25]
Hepatitis B is an occupational health hazard for health-care workers, and meticulous
knowledge about its transmission and preventive measures among medical students is
highly recommended.[20] In a study conducted by Ibrahim and Idris,[14] 71.1% of the students believed that health-care workers are at risk of acquiring
infection from the infected patients as compared to 70.45% of the students correctly
responding in our study. This study shows lack of knowledge among medical students
with regard to different modes of transmission of HBV. The knowledge about transmission
through blood products (81.1%) and use of contaminated needles and syringes (74.2%)
among our study cohort is fairly good. However, awareness about other modes of spread—by
sexual contact with an infected person (28.8%), vertical transmission (23.5%), and
by piercing and tattoo (31.1%) was low. Several studies in other countries too have
revealed similar lack of knowledge among medical students.[19],[20],[21],[22],[24],[25] It was surprising to observe that minority of students (28.0%) had a misconception
that HBV spreads by contaminated food and water. Similar misconception among medical
students was noticed by Aslam et al.[26] The precise knowledge about the modes of transmission among medical students necessitates
them to take protective measures during their clinical postings and also spread awareness
among other health-care workers and general public.
This study also assessed the students’ knowledge regarding clinical features and complications
of hepatitis B infection. HBV primarily affects liver, and patients with acute infection
present with clinical features such as fever, malaise, loss of appetite, nausea and
vomiting, and jaundice. Hepatitis B infection is often asymptomatic in majority of
the patients, and chronic infection ultimately may lead to severe complications such
as cirrhosis and hepatocellular carcinoma, which are associated with high mortality
rate. Among study population, significant percentage of students knew that jaundice
(72.7%) is one of the clinical sign. But their knowledge about other clinical features
of acute hepatitis is low, ranging from 25% to 42%. Majority of the students (81.06%)
were unaware that hepatitis B infection is often asymptomatic. With regard to chronic
complications, more than 50% of the students were unaware that it leads to life-threatening
complications such as cirrhosis (49.2%) and hepatocellular carcinoma (27.8%). Similar
findings were reported in a study conducted on Syrian medical students.[14]
This study revealed surprising results with significant percentage of medical students
who are not vaccinated (14.4%) or not sure about their vaccination status (45.5%),
which makes them vulnerable to hepatitis B. However, survey results revealed that
majority of them were aware of availability of HBV vaccine. Similar findings were
published in a study conducted at College of Medical and Health sciences, Wollega
University, Ethiopia.[19] Hepatitis B is a vaccine-preventable disease and the protective levels of anti-hepatitis
B surface antibodies (anti-HBs) antibodies gradually decline to unprotected levels
over 5–10 years in vaccinated individuals.[27] Therefore, it is emphasized to mandate all medical students to test their anti-HBs
levels as they represent a high-risk population.[14],[28] On the basis of immune status and previous vaccination history, medical students
are advised for boosters, vaccination, or revaccination.
Another issue raised from the results of this study is that medical students lack
knowledge and awareness about HBV transmission, its life-threatening complication,
and the need for health education on HBV. Hence, it is highly advocated that CMHS
must make reforms in its educational curriculum to promote knowledge and awareness
among medical students. In addition, educational reforms should also be focused toward
avoiding infection and seeking immediate medical care in case of accidental exposures
to infected blood and other body fluids. Furthermore, institution should take initiatives
to check the students’ immune status and provide free vaccination to needy students.
Limitation of the study: This study did not measure anti-HBs antibody level to know the immune status of the
participants against hepatitis B. It is recommended for further studies to estimate
anti-HBs levels in the serum of students to know their actual immune status against
hepatitis B.
CONCLUSION
The precise knowledge and awareness about hepatitis B among preclinical year students
at CMHS is lacking. The study findings highlight the necessity of health education
programs for students in the first year itself to improve their knowledge and awareness
of this infectious disease. The proper knowledge helps them to take necessary precautions
during patient care in their clinical years and also to disseminate knowledge and
spread awareness about hepatitis B among other health-care workers and general public.
It is also recommended that institution should take an initiative in measuring hepatitis
B immune status of the students at the time of their entry into medical course and
providing free HBV vaccines to all the incompletely vaccinated and non-vaccinated
students.
