Khurram Nasir ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Khurrarn Ahmad Khan ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Warneez Mohyuddin Kadri ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Shahzad Salim ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Kashif Tufail ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Hina Aziz Sheikh ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Sheikh Asim Ali ( Final Year Medical Students, Allarna lqbal Medical College, Lahore. )
Objective: To study the vaccination status against Hepatitis B among health care workers and students of a medical school.
Materials and Methods: It is a descriptive study done at Allama Iqbal Medical College, Lahore. The participants comprised of 206 health care workers of various categories and 327 medical students. The main outcome measure was vaccination status and reasons for non-vaccination.
Results: Only 49% health care workers and 42.20% medical students were vaccinated. The main reasons for non-vaccination (47.7%) among health care workers was the high cost of vaccination, while the most often cited reason (33.7%) among medical student was the belief that they were not at risk. This belief was also prevalent among nurses (36.4%), laboratory workers (38.6%) and paramedics (33.2%).
Conclusion: In a low-income country like Pakistan the health institutions should bear the cost for vaccinating their staff. Efforts should also be made to impart appropriate health education regarding hepatitis B infection (JPMA 50:239, 2000).
Although the incidence of hepatitis B infection has drastically reduced after the introduction of effective vaccination, modification of high-risk practices and possibly a decrease in the number of susceptible persons1, yet about 400 million people worldwide are carriers of hepatitis2. World Health Report 1999 states that in 1998, hepatitis contributed 0.1% of disability adjusted life years (DALYs)3 .The acute and chronic consequences of hepatitis B infection are major problems both in developed as well as developing world.
Immunization with hepatitis B vaccine is the most effective means of preventing hepatitis B infection and its consequences. The recommended strategy for preventing this infection is selective vaccination of persons with identifiable risk factors. The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B vaccine for every one 18 years of age and younger as well as for adults over 18 years of age who are at risk of hepatitis B infection. Adults who are at increased risk of infection and who should receive vaccination include: sexually active heterosexual adults with more than one sex partner in the prior 6 months or a history of sexually transmitted disease; men who had sex with men; illicit injection dritg users, hemodialysis patients and persons at occupational risk of infection. The health care workers (HCWs) fall in the last category of high-risk group4.
The prevalence of HBsAg positivity among Pakistani health workers has been studied by various authors5-7. The vaccination status of Pakistani HCWs has, however, not been studied in detail. The present study was undertaken to assess the vaccination status of HCWs and medical students of a medical school and its affiliated hospital.
Materials and Method
This study was conducted at Allama lqbal Medical College, Lahore and its affiliated teaching hospital during September 1998.
A questionnaire was circulated among all medical students and HCWs of departments of Medicine, Surgery, Pathology and Community Medicine. The health care workers included Professors, Associate Professors, Assistant Professors, Residents, Interns, Nurses, Technicians and Paramedics.
Eighty-one percent of medical students and 63% of HCWs completed the questionnaire. The data was analyzed using Epi-lnfo,6.
The demographic characteristics of the study population are shown in Table -1 while Table - 2
depicts the vaccination status. Out of 533 subjects only 239 (44.84%) were vaccinated against Hepatitis B. The proportion of vaccinated subjects was slightly higher among HCWs (49%) as compared to students (42.2%). The difference was, however, statistically non significant (P>0.05).
Those HCWs working in the Department of Medicine had the highest vaccination status (58.4%) compared to 42% in Surgery, 45% in laboratory workers and 33.3% among those working in Community Health Department. The difference of vaccination status between those working in Medicine and Surgery was statistically significant (P<0.05). Among HCWs, the highest percentage (83.33%) of vaccination was in teaching staff (Assistant Professor/Associate Professor/Professor). Only 40.6% nurses and 45% laboratory workers were vaccinated, while none of the paramedics were vaccinated.
The reasons for non-vaccination among HCW and students are shown in Table 3.
The most common reason (47.7%) among HCWs was the high cost of vaccination, while most frequently cited reason (33.7%) by the students was the belief that they were not at risk of acquiring hepatitis.
The sero-prevalence of Hepatitis B among various groups of Pakistani population is estimated to be around 3%8-12 The prevalence of HB5Ag positivity among Pakistani health workers ranges from 5.2% among subjects studied by Zahid et al.6 in 1991 to 7.5% among 114 operating room personnel examined by Mujeeb13 et al. in 1998.
Table-4 compares the HBsAg positivity of Pakistani HCWs with similar studies from other countries. The seroprevalence of Hepatitis B among Pakistani HCWs is higher than Nepal14 (2.6%) and Greece15, (2.6%) but lower than Portugal16 (16.8%), and corresponds closely to prevalence reported from Thailand17 (6.6%) and Egypt18 (6.6%).
The sero-prevalence of hepatitis among medical students of Pakistan5 (5.7%) is similar to that reported by Marinho et al17 from Portugal (5.5%). A similar study from India shows that only 2.3% of medical students were seropositive for hepatitis B19.
The vaccination status of Pakistani HWCs is lower than the figures reported from USA20,21, (40-78%) and UK22,23 (79-88%). A report from the University of California at Los Angeles24, Los Angeles USA, also shows that only 40% of Pathologists and 51.9% Gynecologists were vaccinated (Table 5).
Only 42.2% of medical students were vaccinated; of whom only 36% of 114 operating room personnel reported by Mujeeb et al were vaccinated; 47.33% were from of pre-clinical years and 3 8.77% from clinical years (Table-2). This may appear to be a paradoxical finding but the reason is that for the last three years, all new entrants to our medical school are made aware of the importance of vaccination against Hepatitis B. Many students now get vaccinated during the first year of medical school. This trend is reflected in the higher proportion of vaccinated students in pre-clinical years.
The major reason of non-vaccination (44.7%) among HCWs was the high cost of vaccination, while the main reason cited by the students (33.7%) was the belief that they were not at risk. In Pakistan, there is no medical insurance and most hospitals do not bear the cost of vaccination of their staff Due to high cost of. vaccination, most HCW do not get vaccinated for it. The cost of the complete course of vaccination in Pakistan is about Rs. 1200 (US $ 25.00). This is approximately equivalent to the 10 days salary of an vaccination be provided free, while 41.2% agreed to pay less than Rs. 250(US $ 5.00).
The fact that 36.3% of medical students, 54.6% of staff nurses, 3 8.6% of the laboratory workers and 68.6% of the paramedics were either not informed about the importance of vaccination or they did not consider them to be at risk, calls for the institution of appropriate health education program.
We are very grateful to Dr. N. Rehan, Director Research, Pakistan Medical Research Council, FJMC, for his guidance and cooperation in completing the article.
1.Centers for Disease Control and Prevention. Viral hepatitis B- Fact Sheet. www.edc.gov/ncidodldiseaseslb/fact htm.
2.Sriedman LS. Liver, Biliarv Tract and Pancreas, In: Tierney LM, McPhee Si, Papadakis MA, editors. Current Medical Diagnosis and Treatment. 38th Edition, USA: Appleton and Lange, 1999, pp. 637-677.
3.World Health Organization. World Health Report 1999. Geneva: World Health Organization, 1999.
4.Centers for Disease Control and Prevention. Immunization of adolescents: Recommendation of the Advisory Committee on Immunization Practices, American Acadeniy of Pediatrics, American Family Physicians and American Medical Association. MMWR, 1996:45:1-14.
5.Khan GM, Malik MN, Rana K, et al. Profile of hepatitis B surface antigen positivity in health care personnel. Mother and Child, 1996:34:135-38.
6.Zahid MA, Rehman K, Janjua IM, et al. Prevalence of Hepatitis B in health care workers in a general hospital. Pak. J. Med., 199130:398-400.
7.Shah SH, Khan JA, Khan MH, et al. Prevalence of Hepatitis B in hospital staff, Pak. J.Med. Res., 1988:27:168-169.
8.Marri SM, Ahmad J. prevalence of Hepatitis B antigenimia in general population of Quctta Balochistan. Biomedica, 1997:13:51-52.
9.Chaudrv NT. Prevalence of Hepatitis B carriers and blood group frequency in voluntary blood donors. J. Ayub Med. Coil., 1996:8:29-32.
10.Agboatwalla M, Isomura S. Yashimata T, et al. Hepatitis A, B and C seroprevalencc in Pakistan. Indian J. Pediatr., 1994:15545-49.
11.Shah HA, Prevention of hemotropic viral infection. Trop. Gastroerol., 1994:15:55-63.
12.Abbas KA, Tanwani AK. Prevalence of Hepatitis 13 surface antigenimia in healthy children, J. Pak. Med. Assoc., 1997:47:93-94.
13.Mujeeb SA, Khatri Y, Khannai R. Frequency of parenteral exposure and seropravelance of HBV, HCV and H1V among operation room personnel. Infect. Control Hosp. Epidemiol., 1997; 18:680-81.
14.Shrestha SM. Sero Epidemiology of Hepatitis B in Nepal. J Commun Dis 1990:22:27-32.
15.Panis B, Roumeliotou-Karayannis A, Papaevangelou 0. et at. Hepatitis B virus infection in dentists and dental students in Greece. Oral. Surg. Oral. Med. Oral. Pathol., 1986:61:343-45.
16.Marinho RT, Motmra MC, Pedro M. et at. Hepatitis B vaccination in hospital personnel and medical students. J. Clin. Gastroenterol., 1999:28:317-22.
17.Chokbunyasit N, Potacharoen 0, Sirisanthana f Prevalence of HBV infection in nurses and manual workers in Maharaj Nakorn Chiang Mai Hospital. J. Med. Assoc. Thai., 1995:78(Suppl l):Sl9-25.
18.El-Zavadi AR, Abe K. Selim 0. et al. Prevalence of GB V-C/hepatitis 0 virus viraemia among blood donors, health care personnel, chronic non-B non-C hepatitis, chronic hepatitis C and hemodialysis patients in Egypt. J. Virol. Methods, 1999:80:53-58.
9.Khurana V. Kar P. Manshararnani N. et at. Differences in hepatitis B markers between clinical and pre-chinical health care personnel. Trop Gestroenterol 1997:18:69-71.
20.Mahoney Fi, Stewart K, Hii 11, et al, Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Arch Intern Med 1997:8-22:157:2601-5.
21.Lee DJ, Carrillo L, Felnimng L. Epidemiology of hepatitis B vaccine acceptance among urban paramedics and emergency medical technicians. Am J Infect Control 1997:25:421-3,
22.Smith ER, Banatvala JE, Tilzey AJ. Hepatitis 13 vaccine uptake among surgeons at a London teaching hospital: how well are we dong? Ann R CoIl Surg EngI 1996;78:447-9.
23.Nec PA, Randall PE, Heyworth J. Hepatitis B vaccination: uptake by medical staff in accident and emergency departments. J Accid Emerg Med 1995;12:282-5
24.Murata Pi, Young LC. Physicians’ atiitudes and behaviors regarding hepatitis B Immunization, J Fam Pract 1993:36:163-8.