Attitude and Vaccination Status of Healthcare Workers against Hepatitis B Infection in a Teaching Hospital, Ethiopia.
Hepatitis B infection has been a major public health threat that affects nearly two billion people worldwide with 350 million chronic cases and more than 2 million deaths every year . The disease is mainly transmitted by percutaneous or mucosal exposure to infected blood or other bodily fluids and numerous forms of human contact have been suggested to transmit hepatitis B virus (HBV): perinatal/mother-to-child, nonsexual, sexual, needle-sharing, and occupational/healthcare-related forms . The disease causes chronic infection, resulting in cirrhosis of the liver, liver cancer, liver failure, and death. Furthermore, extrahepatic lesions can occur in other organs of the body, particularly in the kidney .
Since contact with body fluid of an infected person is one of the principal modes of transmission of the causative virus of hepatitis B infection, healthcare workers (HCWs) constitute one of the high-risk groups for this infection because of their repeated exposure . World Health Organization (WHO) estimated that, of the 35 million HCWs worldwide, 3 million experience percutaneous exposure to blood pathogens each year and 2 million of those HCWs are exposed to hepatitis B virus [5-8]. In general, prevalence of HBV infection among healthcare providers is approximately ten times greater than the general population . More importantly, HCWs in developing countries are at serious risk of infection from blood-borne pathogens because of the high prevalence of such pathogens in many poorer regions of the world, especially in endemic areas like Sub-Saharan Africa .
Due to the absence of medical treatment that can cure hepatitis B virus (HBV) infection, hepatitis B vaccine is the single most effective and safe strategy for the prevention of the disease if appropriate doses are given during a period of 6 months. The vaccine provides more than 90% effective protection after all doses [11, 12]. As part of occupational safety measures, WHO, Centers for Disease Control and Prevention (CDC), and the Ethiopian Federal Ministry of Health (FMOH) infection-prevention guidelines recommend that all health professionals should be vaccinated against HBV before they started the clinical attachments during their stay in the medical school [13-15]. However, in spite of higher vulnerability among health professionals, the WHO estimate showed that HBV vaccination coverage among HCWs is only 18-39% in low- and middle-income countries compared to 67-79% in developed countries .
In Ethiopia, hepatitis B infection cases account for 12% of the hospital admissions and 31% of the mortality in medical wards of Ethiopian hospitals . Specifically, studies conducted on health professionals revealed 9.7% prevalence of hepatitis B surface antigen (HBsAg) . On top of that, some studies also reported lower coverage of hepatitis B vaccination among health professionals [18-21]. Therefore, this study aimed to assess the attitude and vaccination status of health professionals against hepatitis B virus infection and factors associated with complete immunization.
2.1. Study Design and Setting. The study was conducted at Adama General Hospital and Medical College, Adama, Ethiopia. The city is located 99 km away from Addis Ababa, the capital city of Ethiopia, to the southeast. This teaching hospital has catchment population of about 5 millions, serving as referral hospital for all nearby hospitals and adjacent regions. It has more than 500 healthcare workers providing the service in different units. This is an institution-based cross-sectional study conducted from December 2016 to February 2017.
2.2. Study Participants. All health professionals working at Adama General Hospital and Medical College were included into the study irrespective of their working unit and duration of stay to minimize the risk of selection bias.
2.3. Variables and Measurement. Complete immunization against hepatitis B virus and attitude of healthcare workers towards hepatitis B infection and its vaccination were the outcome variables measured in the study, whereas various sociodemographic variables (age, profession, working unit, and years of work experience) and occupational variables (training on infection-prevention and history of exposure to risky behavior) were the independent variables. Complete immunization was measured using the following question: "how many doses of the vaccine have you taken?" Taking three or more doses of the vaccine was defined as complete immunization. Attitude was measured on the cumulative score of thirteen questions designed to assess healthcare workers' attitude towards hepatitis B infection and its vaccination. Each attitude question contains ordinal categorical response rated in 5-point Likert scale [i.e., 1 = strongly disagree; 5 = strongly agree] and these questions were adapted from previous literatures [19, 22, 23]. Overall, the scores for each participant were summed and study participants who have responded to >60% of attitude questions positively were regarded as having favorable attitude.
2.4. Sample Size and Sampling Procedure. Single population proportion formula was used to calculate the sample size given the prevalence of hepatitis B vaccination for healthcare workers of 50% to obtain a relatively larger sample size, confidence level of 95%, and marginal error of 5%. The final sample size was 403 after adjustment for 5% nonrespondent rate. The total sample size was proportionally allocated to each of the working departments in the hospital. The list of health professionals working in each department was obtained from the hospital and simple random sampling technique was employed to select the study subjects from the list.
2.5. Data Collection and Quality Control. Data were collected using self-administered questionnaire distributed at the participant's work unit. Data collection was performed by three nursing professionals through distributing and recollecting the questionnaire prepared in English. Pretesting was performed on 5% of the total sample size in other health facilities and a necessary adjustment was made prior to the actual data collection. The questionnaire was also tested for internal consistency (reliability) by Cronbach's Alpha test using Statistical Package for Social Sciences (SPSS) version 20.0. Similarly, content validity was cross-checked by a public health expert. The completeness, consistency, and accuracy of the collected data were examined by principal investigator every day.
2.6. Data Processing and Analysis. The data were coded, cleaned, and entered into Epi Info version 7 and it was exported to SPSS version 20 for statistical analysis. First, descriptive statistics were generated followed by binary and multiple logistic regressions to examine the possible association between the determinant and the outcome variable. In this model, P value < 0.05 was used to declare the presence of statistically significant association. The result was reported strictly following STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) statement (supplementary file (available here)).
3.1. Sociodemographic Characteristics of the Study Participants. A total of 386 participants completed the questionnaire, making a response rate of 97%. More than half (198 (51.2%)) of participants were male and the age of study participants ranged from 21 to 64 with the mean age of 28.45 ([+ or -]3.2) years. The professional background of respondents was dominated by nurses (203 (52.7%)) followed by medical doctors (52 (13.5%)) (Table 1).
3.2. Attitude towards Hepatitis B Infection and Its Vaccination. More than three-fourths (77.8%) of study participants strongly agreed that hepatitis B is a major public health threat. Similarly, more than half (51.2%) of healthcare workers strongly agreed that hepatitis B vaccine should be obligatory to take. There was tendency among participants to believe that their profession will put them at increased risk of acquiring the disease (strongly agreed: 75.9%). Participants also stated that following the infection-prevention guideline has a potential benefit on reducing the chance of contracting hepatitis B infection (strongly agreed and agreed: 85.2%) (Table 2).
3.3. History of Occupational Exposure and Perceived Risk of Disease Acquisition. Healthcare workers were asked to rate their perceived risk of acquiring the infection. The respondents reported that they have very high (51 (13.3%)), high (80 (20.7%)), medium (101 (26.1%)), low (142 (36.9%)), and very low (12 (3%)) risk of contracting the disease. Nearly half (182 (47.3%)) of healthcare workers had history of occupational exposure to risky conditions. Unprotected mucocutaneous fluid contact on intact skin (121 (66.7%)), sharp-needle injury (72 (39.6%)), and body fluid splash through body openings (51 (28.1%)) represent the three main forms of exposure. The most common (130 (71.3%)) action taken after the exposure was washing the area of exposure with soap, water, or antiseptic (Table 3).
3.4. Vaccination and Postvaccination Testing. Only three in ten (118 (30.4%)) participants had been screened for hepatitis B surface antigen. Regarding the vaccination status of study participants, more than half (223 (57.7%)) of them reported history vaccination at least once. However, less than half (99 (44.5%)) of these participants received the recommended three doses of the vaccine, of which 36 (36.8) tested after the vaccine to check for the vaccine effect and all of them were protected (anti-HB titer > 10 MIU/ml). Among healthcare workers who did not take the vaccine, vaccine unavailability through government channels (36%), high cost of the vaccine for private access (41%), and not giving much concern about this issue (26%) represent the major reasons stated for not being vaccinated (Table 4).
3.5. Factors Associated with Vaccination Status. Multivariate analysis of factors affecting the practice of full dose vaccination revealed that previous exposure to occupational risks of hepatitis B infection, years of work experience and infection-prevention training were statistically significant with complete vaccination status. Participants whose years of work experience were [greater than or equal to]5 years had 3 times (AOR = 3.1 (.98-5.24)) greater chance of receiving the vaccine. Likewise, previous history of exposure to occupational risks of hepatitis B infection resulted in 5.5 times (AOR = 5.5 (2.86-9.29)) increased practice of receiving full dose vaccine. Similarly, participants who attended infection-prevention training were 2.3 times (AOR = 2.3 (1.24-6.31)) more likely to take the recommended vaccine dose than their counterparts (Table 5).
Hepatitis B vaccination is one of the most important primary prevention ways of this contagious disease and immunization against this infectious agent provides an optimal protection for individuals at risk . World Health Organization estimated that hepatitis B vaccine's coverage among healthcare providers is 18% in Africa, which represents the least figure . Therefore, this study assessed the coverage of hepatitis B vaccine among healthcare workers of Adama General Hospital and Medical College, Ethiopia.
In this study, it appeared that the proportion of healthcare workers who received hepatitis B vaccine at least once was 57.7%. This finding is in the range of 47%-60% reported in different studies of different areas [20, 26-28]. However, the result is relatively lower compared to the findings reported from Iraq (65.7%), Kuwait (74.4%), India (78%), and Nigeria (91.9%) [29-32]. The complete reason for low vaccine coverage of our survey compared to these studies cannot be completely discernible. However, difference in vaccine accessibility across countries, relatively late addition of hepatitis B vaccine into national immunization program, and certain variability between the sociodemographic characteristics of the study participants might explain this discrepancy. The proportion of healthcare workers who completed the recommended three or more doses of the vaccine constitutes 25.6% of the whole study participants. This figure is lower compared to reports of other studies conducted in Pakistan (57.6%), Malaysia (58.6%), and Libya (72%) [33-35]. This lower rate of complete immunization reflects the need for well effective strategy that enhances increased rate of compliance with recommended vaccine doses. Furthermore, health professionals have to be supported and inspired to check their protection status to make sure whether or not they require additional doses of the vaccine to get protected.
Regarding the attitude of healthcare workers towards hepatitis B infection and its vaccination, the majority of them showed encouraging positive attitude towards the issue. The majority (77.8%) of healthcare workers strongly agreed that hepatitis B is a major public health threat and almost all (96.5%) of them stated that their job puts them at risk of acquiring the disease. Regarding the importance of vaccination, around 75% of healthcare workers agreed that hepatitis B vaccination should be compulsory. These statements are also similarly reported at comparable rate in other studies conducted in Kuwait and Gondar University Hospital [30, 36].
Among healthcare workers who did not receive the vaccine, the most frequently mentioned reason was high cost of the vaccine for private access. Similarly, studies from different areas reported the same finding [20, 22, 37, 38]. Another barrier mentioned was vaccine unavailability, which was reported by 36% of participants. Likewise, this report is in line with the reasons mentioned for vaccine refusal in different articles [19, 28, 39]. This is an input for stakeholders to establish an effective program that focuses on vaccine availability at affordable cost to meet the demand of healthcare workers. According to our study, nearly half (47.3%) of healthcare workers have been exposed to risky situation for hepatitis B infection. Of these, 39.6% reported exposure to sharp-needle injury. A study conducted in Pakistan reported that the percentage of healthcare workers who had experienced at least one sharp injury in a year was 44% and another study conducted in Gondar University Hospital also revealed that 49.2% of healthcare workers had been exposed to occupational risks [36, 40]. This evidence emphasizes the importance of hepatitis B vaccination for this group of people in particular given the extent of their exposure.
This study revealed that healthcare workers who have been exposed to risky conditions of hepatitis B virus had increased chance of receiving complete immunization. This finding is in line with reports from north India, Zambia, and northwest Pakistan [23, 28, 41]. This might be because of increased perceived threat of getting such blood-borne disease after exposure to risky conditions. Years of work experience were another important factor that influenced the complete vaccination status of healthcare workers. Similarly, other studies showed that there was an increased chance to get full vaccination with increasing number of years of work experience [21, 42, 43]. This might be because of the fact that healthcare workers who joined the institutions later might not have benefited from vaccination because of sporadic availability of the vaccine through government channels. Likewise, increased length of work years would result in higher rate of exposure to various risky behaviors, which in turn leads to increased perceived threat of acquiring the disease. Participants who attended infection-prevention training showed increased rate of complete immunization. Studies from Zambia and Nigeria revealed the same finding . This result shows that provision of basic infection-prevention training for all hospital might have a benefit in terms of lifting up the perceived benefit of such preventive strategies among healthcare workers.
Despite extensive efforts that have been made to minimize possible shortcoming of this study, the finding of this survey will be interpreted in the presence of the following inevitable limitations. The cross-sectional nature of the study does not confirm the definitive cause-and-effect relationship. There is also a possibility of admitting recall bias because of the self-reported vaccination status.
Only a small proportion of healthcare workers have taken the recommended three doses of the vaccine at Adama General Hospital and Medical College. Attending infection-prevention training, work experience, and history of exposure to risky condition were the factors that are statistically significant with the completion of the recommended three doses. High cost of the vaccine for private access and vaccine unavailability were the major barriers identified for hepatitis B vaccination. Sustained HBV vaccination programs for HCWs need to be established by collaboration of different stakeholders. Moreover, the Regional Health Bureau should offer the vaccine to HCWs free of charge by coordinating efforts from other concerned bodies. Similarly, the government should design a national strategy that focuses on vaccinating medical and health science students before they are assigned to their work place.
The original raw data analyzed during the current study is available from the corresponding author and can be presented upon reasonable request.
Ethical clearance was obtained from the Ethical Review Committee of Institute of Medicine and Health Science, University of Debre Berhan.
The respondents were informed about the purpose of the study and their consent to participate was obtained.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Mohammed Akibu designed the study, supervised the data collection, performed analysis and interpretation of data, and organized the paper and all versions of the manuscript. Sodere Nurgi, Mesfin Tadese, and Wendwesen Dibekulu Tsega were actively involved in supervision of the data collection, data analysis, and preparation of this manuscript. All authors read and approved the final manuscript.
The authors would like to pass their gratitude to the University of Debre Berhan for the ethical clearance. They also want to send their appreciation to the study participants for giving their genuine information.
Supplementary file 1: completed checklist of STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) for cross-sectional studies. STROBE Statement--Checklist: Attitude and Vaccination status of Health care workers against Hepatitis B infection in a Teaching Hospital, Ethiopia. (Supplementary Materials)
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Mohammed Akibu (iD), (1) Sodere Nurgi, (1) Mesfin Tadese (iD), (1) and Wendwesen Dibekulu Tsega (2)
(1) Department of Midwifery, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia
(2) Department of Public Health, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia
Correspondence should be addressed to Mohammed Akibu; email@example.com
Received 4 November 2017; Revised 5 February 2018; Accepted 1 March 2018; Published 2 April 2018
Academic Editor: Paulo Hiiario Nascimento Saldiva
Table 1: Socio-demographic characteristics of health professionals, AHMC, Ethiopia 2017. Variable Frequency (n = 386) Percent (%) Sex Male 198 51.2 Female 188 48.8 Age (years) 20-30 33 16.3 31-40 94 46.3 >40 7 3.4 Marital status Unmarried 210 54.4 Married 176 45.6 Religion Orthodox 266 69 Protestant 72 18.7 Muslim 35 8.9 Other (a) 13 3.4 Profession Nurse 203 52.7 Midwife 44 11.3 Lab technician 25 6.4 General Practitioner 52 13.5 Dental Doctor 14 3.6 Pharmacist 20 5.2 Specialist 28 7.3 Working department Inpatient department 92 23.8 Outpatient 114 29.5 Emergency department 36 9.3 Delivery unit 53 13.8 Laboratory 28 7.3 OR department 32 8.3 Dental department 31 8 Work experience <5 years 227 58.7 [greater than or 159 41.3 equal to] 5 years Training on infection prevention Yes 224 58 No 162 42 (a) catholic, woke feta, Adventist. Table 2: Attitude of health professional towards hepatitis B infection and its vaccination, AHMC, Ethiopia, in 2017. Items Strongly agree Agree Neutral HBV is serious 300 (77.8%) 70 (18.2%) 4 (1.0%) public health problem All patients 80 (20.7%) 116 (30.1%) 99 (25.6%) should be tested for HBV before they receive healthcare Being a health 292 (75.9%) 80 (20.6%) 8 (2%) professional puts you at greatest risk of HBV infection Following 203 (52.7%) 125 (32.5%) 21 (5.4%) infection control guidelines will protect me from being infected with HBV and HCV at work I deliver the same 46 (11.8%) 148 (38.4%) 32 (8.4%) standard of care to patients with HBV as I do for other patients It is appropriate 91 (23.6%) 109 (28.2%) 46 (11.8%) not to spend much time when caring HBV-infected patients A healthcare 112 (29.1%) 141 (36.5%) 15 (3.9%) worker can infect patients with HBV Health 25 (6.4%) 32 (8.4%) 63 (16.3%) professionals who are hepatitis B virus-positive should not give healthcare services to patients I do not trust HBV 17 (4.3%) 45 (11.7%) 54 (14%) vaccine HBV vaccine should 198 (51.2%) 91 (23.7%) 25 (6.4%) be compulsory HB vaccine is safe 236 (61.1%) 89 (23.2%) 36 (9.4%) but is expensive After exposure to 122 (31.5%) 97 (25.1%) 49 (12.8%) contagious flu-id- material, the vaccine reduces likelihood of being HBV- positive Items Disagree Strongly Disagree HBV is serious 10 (2.5%) 2 (0.5%) public health problem All patients 68 (17.7%) 23 (5.9%) should be tested for HBV before they receive healthcare Being a health 4 (1%) 2 (0.5%) professional puts you at greatest risk of HBV infection Following 29 (7.4%) 8 (2,0%) infection control guidelines will protect me from being infected with HBV and HCV at work I deliver the same 101 (26.1%) 59 (15.3%) standard of care to patients with HBV as I do for other patients It is appropriate 72 (18.7%) 68 (17.7%) not to spend much time when caring HBV-infected patients A healthcare 78 (20.2%) 40 (10.3%) worker can infect patients with HBV Health 118 (30.5%) 148 (38.4%) professionals who are hepatitis B virus-positive should not give healthcare services to patients I do not trust HBV 109 (28.3%) 161 (41.7%) vaccine HBV vaccine should 64 (16.7%) 8 (2%) be compulsory HB vaccine is safe 13 (3.4%) 12 (3.0%) but is expensive After exposure to 80 (20.7%) 38 (9.9%) contagious flu-id- material, the vaccine reduces likelihood of being HBV- positive Table 3: Exposure to occupational risk of hepatitis B among health professionals, AHMC, Ethiopia, in 2017. Variable Frequency Percentage Occupational exposure Yes 182 47.3 No 204 52.8 Exposure to sharp injury Yes 72 39.6 No 110 60.4 Unprotected mucocutaneous fluid contact on intact skin Yes 121 66.7 No 61 33.3 Body fluid contact through body openings Yes 51 28.1 No 131 71.9 Measure taken after exposure Testing the patient right away 71 39 Washing with soap, water, or 130 71.3 antiseptic Immediate report 80 44.2 Allowing the injury area to bleed 25 14 Wait and test myself 11 6.2 Table 4: Vaccination status and reason for not taking the vaccine among health professionals, AHMC, Ethiopia, in 2017. Variables Frequency Percentage N (%) Ever screened for hepatitis B Screened 118 30.4 Not screened 268 69.6 Vaccination for hepatitis B Vaccinated 223 57.7 Not vaccinated 163 42.3 Vaccination dose Once only (incomplete vaccination) 75 33.6 Received two doses (incomplete 49 21.9 vaccination) Three complete doses (fully 99 44.5 vaccinated) Complete vaccination status Fully vaccinated 99 44.5 Incomplete vaccination 124 55.4 Have you been tested after full dose? Tested for the vaccine effect 36 36.4 Not tested 63 63.8 Test result Protected (anti-HB titer > 10 MIU/ml) 36 100 Reason for incomplete vaccination Being busy 47 37.9 I feel I am protected 15 12.2 Forget it at all 28 22.6 Waiting for the next dose 34 27.3 Reason for not taking the vaccine The vaccine was not available through 59 36 government channels The vaccine is very expensive for 67 41 private access I did not give it too much emphasis 42 26 The side effect would be worse 13 8 The duration of total dose is too long 25 15.4 Others (b) 6 3.7 (b) I do not think I am at risk, I never thought about it, or I have no reason. Table 5: Logistic regression of factors affecting full vaccination status among HCWs who received at least one dose, AMHC, Ethiopia, in 2017. Variable Fully vaccinated Yes No Sex Male 37 49 Female 62 75 Work experience <5 years 28 74 [less than or equal to] 5 years 71 50 Profession Nurse 35 45 Midwife 14 17 Lab technician 12 13 General practitioner 16 19 Pharmacist 5 8 Dental doctor 6 9 Specialist 11 13 Training on IP Yes 67 48 No 32 76 Work unit Inpatient unit 12 25 Dental department 4 11 Emergency unit 13 16 Delivery unit 23 21 Laboratory 21 7 OR department 6 13 Outpatient unit 20 31 Exposure history Yes 73 38 No 26 86 Variable COR (95% CI) Sex Male 1 Female 3.45 (1.82-6.7) Work experience <5 years 1 [less than or equal to] 5 years 4.8 (2.64-7.44) * Profession Nurse 0.87 (0.67-2.13) Midwife 1.5 (0.68-2.75) Lab technician 2.6 (1.36-5.71) * General practitioner 2.1 (0.92-6.37) Pharmacist 1.65 (0.401-4.62) Dental doctor 1.39 (0.44-3.64) Specialist 1 Training on IP Yes 3.4(2.77-8.92) * No 1 Work unit Inpatient unit 2.93 (2.91-7.68) Dental department 0.063 (0.0057-0.84) Emergency unit 1.4 (0.63-3.18) Delivery unit 4.64 (1.43-19.7) * Laboratory 5.45 (1.74-9.27) * OR department 1.39 (0.34-3.24) Outpatient unit 1 Exposure history Yes 6.4 (3.43-11.58) No 1 Variable AOR (95% CI) Sex Male 1 Female 1.06 (0.84-3.62) Work experience <5 years 1 [less than or equal to] 5 years 3.1 (1.98-5.24) * Profession Nurse 0.22 (0.03-1.45) Midwife 0.6 (0.07-4.64) Lab technician 1.72 (0.89-2.42) General practitioner 0.03 (0.04-2.21) Pharmacist 0.82 (0.27-3.91) Dental doctor 1.57 (0.38-6.19) Specialist 1 Training on IP Yes 2.3 (1.24-6.31) * No 1 Work unit Inpatient unit 1.07 (0.94-3.75) Dental department 0.071 (0.003-1.83) Emergency unit 1.6 (0.71-4.2) Delivery unit 2.48 (0.82-7.29) Laboratory 2.16 (0.018-6.23) OR department 1.56 (0.40-6.24) Outpatient unit 1 Exposure history Yes 5.5 (2.86-9.29) * No 1 * indicates statistically significant value.
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|Title Annotation:||Research Article|
|Author:||Akibu, Mohammed; Nurgi, Sodere; Tadese, Mesfin; Tsega, Wendwesen Dibekulu|
|Date:||Jan 1, 2018|
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