Perception of dental students toward Hepatitis B and its vaccine - A cross-sectional study

INTRODUCTION

The hepatitis B virus (HBV) is a global public health problem, particularly in developing countries, that can cause chronic infections, cirrhosis, and liver cancer.^[1] According to the World Health Organization (WHO), hepatitis is a life-threatening viral infection caused by the HBV that occurs inside the liver and causes acute and chronic diseases. It ranks among the most common viral infections that are prevalent and can affect the population.^[2] HBV is the tenth leading cause of death throughout the world, and 500,000-1.2 million deaths per year are due to chronic hepatitis, cirrhosis, or hepatocellular carcinoma^[3] and it is an important reason for morbidity and mortality in the Indian population with a prevalence between 2% and 7%.^[4] Approximately 14.4 and 1.4% of HBV and hepatitis C virus (HCV) infections have been reported in healthcare workers, respectively, the highest prevalence being among dentists, nursing staff, dialysis unit staff, laboratory staff, and physicians.^[5]

HBV is a deoxyribonucleic acid virus that replicates through a ribonucleic acid intermediate. Only hepatic tissue is where HBV replicates. The blood of an infected person may contain 106-1010 international units when the virus is actively replicating per mm, and as a result, parenteral or mucosal contact with a tiny amount of blood or bodily fluid may result in infection in those who are vulnerable.^[6] In dental practice, transmission takes place because of fluid exposures through cutaneous scratches, abrasions, burns, different lesions, or through direct or oblique touch with blood and/or on mucosal surfaces. Hepatitis B contamination may be contagious because of touch with blood, semen, vaginal secretions, and other fluids from human beings stricken by hepatitis B contamination.^[7] Infection of patients within the dental healthcare setting can occur in similar ways to the dentists themselves. Concern for their health may even entice dentists to refuse treatment of HBV-infected patients.^[8] Studies have shown that the risk of acquiring hepatitis B infection among dentists is about 3-4 times greater than for non-immunized surgical specialists and about 6 times greater than that of the general population.^[9]

The countries’ inability to face the hepatitis B burden due to political and financial problems may, thereby, pose a substantial obstacle to prevention.^[10] Knowledge, attitude, awareness, access to screening, and vaccination of healthcare providers remain poor in many developing countries, including India.^[11] To develop and conduct an initiative to raise awareness of standard safety precautions for the prevention of HBV infection, it is essential to determine the level of HBV vaccination coverage and evaluate dental students’ knowledge about the disease and its transmission. Therefore, this study contemplated determining HBV vaccination coverage and the level of knowledge of HBV among students pursuing dentistry at a private dental college in Chengalpattu district.

MATERIALS AND METHODS

An analytical cross-sectional study design was used to determine the knowledge about the HBV and its vaccination and immunization status of dental students. This study was conducted in a private dental college on final-year, interns, and postgraduate dental students in the Chengalpattu district over 6 months from July 2023 to December 2023. Only students who were present during the designated period for data collection were included in the study; these students comprised interns, postgraduates, and final-year undergraduates. The 1^st-year, 2^nd-year, and 3^rd-year undergraduates were not included in the study. Furthermore, the study did not include students who chose not to participate in the study. The Institutional Review Board gave its approval to the study’s protocol before it started [KIDS/IEC/2024/I/004]. The subjects’ anonymity was preserved throughout the research. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE initiative)^[12] guidelines provided a framework for the study design. Twenty-five dental students participated in a pilot study to determine the sample size and assess the study’s feasibility. The reliability test showed an acceptable Cronbach’s alpha value of 0.74 to proceed with the study. The participants enrolled in the pilot study were not included in the main study. Using G power software (Version 3.1.9.7), the sample size was determined with 80% statistical power, α = 0.05, 95% confidence interval, 10% margin of error (E), and knowledge of hepatitis (62%). It was estimated that the final sample was 200 participants in the study.

The study instrument comprised 20 closed-ended questions on the questionnaire. It was divided into three sections: Demographics; knowledge assessment, which included ten questions about knowledge related to HBV infection; “Transmission” of HBV, which included five questions about the different ways that HBV infection can spread; and “Complications of HBV,” which included five questions with Yes/No answers about infection control procedures and the effects of Hepatitis-B. The participants’ demographic characteristics, their coverage of the hepatitis B vaccination, and the dental students’ status regarding booster doses were all considered independent variables. The questionnaire was assessed for content validity index (CVI) relevance, with simplicity, ambiguity, and objectivity checked, and the CVI score is 0.78. At the end of the lecture or during the clinical sessions, students were asked to complete the anonymous, self-administered, pre-validated questionnaire. The study’s purpose was conveyed to final-year students, interns, and postgraduates, and the data were obtained from the respondents.

A Microsoft Excel sheet was used for all data management, and the Statistical Package for the Social Sciences software version 22 (International Business Machines Corp., Armonk, NY, USA) was used for data analysis. For all continuous quantitative variables, we estimated the mean and standard deviation. For all categorical variables, we computed the frequencies and percentages. With statistical significance set at 0.05, the Chi-square test was used to determine the differences between participants’ knowledge scores that were statistically significant. A Spearman’s correlation test was used to assess the correlation.

RESULTS

The study sample consists of 200 dental students from the private dental college in Chengalpattu district. The sample population ranges in age from 21 to 24 years old, with a mean age of 23.49 ± 1.56 years. Out of 200 dental students, 141 (69.8%) were female and 59 (29.2%) were male. Of the overall study participants, 40 (20%) were postgraduates, 80 (40%) were final year students, and 80 (40%) were interns. Approximately 86% of the population had received vaccinations, whereas 14% had not. Most respondents (70%) received all three doses of the hepatitis B vaccine [Table 1]. The results showed that 97.5% of final years, 98.8% of interns, and 100% of postgraduates were aware of the HBV virus. About 61.3% of final years, 78.8% of interns, and 85% of postgraduates responded that HBV is symptomatic and is statistically significant with a value of P = 0.007. Most of the students stated that HBV is a life-threatening condition and is statistically significant between 3 years (P = 0.002). When asked about whether dentists are prone to HBV, 90% of final years agreed with the question followed by 95% of interns and 95% of postgraduates, which amounted to no statistically significant difference (P = 0.398). This survey showed that 46.3% of final years responded that there is no family history of hepatitis, followed by 70% of interns and 77.5% of postgraduates, reflecting a statistically significant difference (P = 0.001). In terms of vaccine against this disease, there was no statistically significant difference between the final year (98.8%), interns (100%), and postgraduates (100%) (P = 0.471). In addition, 57.5% of final years, 63.7% of interns, and 77.5% of post-graduates were aware of the doses (three booster doses) that should be taken, which is statistically significant (P = 0.002) [Table 2].

Table 3 shows the results obtained regarding the transmission of the HBV. For most of the questions, no differences were identified between students from different years. About 82.5% of final years, 88.8% of interns, and 97.5% of post-graduates reported that hepatitis B is a transmissible disease, and it was found to be statistically significant (P = 0.056). The results obtained showed that 88.8%, 83.8%, and 100% (final years, interns, and postgraduates) responded that HBV can be transmitted through dental treatments, and it was found to be statistically significant (P = 0.027). Regarding the possible mode of HBV transmission through saliva, results showed highly significant differences (P = 0.000) between final-year students, interns, and postgraduates, in which the postgraduates (75%) answered better than final years and interns (32.5% and 26.3%, respectively). No significant differences between the 3 years were found regarding the question about patient-to-patient transmission (P = 0.125) and patient-to-dentist transmission (P = 0.28). The dental students demonstrated knowledge about the complications of the HBV. Most of the questions were directed to them, specifically regarding the following: Experience in treating hepatitis patients, risk of jaundice, and cirrhosis. About 37.5% of postgraduates are experienced in treating hepatitis B-infected patients, and only 7.5% of final-year students came across HBV patients with significant differences according to the academic level (P = 0.000). Regarding the respondents’ knowledge about jaundice, acute HBV was mentioned as a cause with a statistically significant difference between the different years (P = 0.003), i.e., the highest proportion (85%) of correct responses came from postgraduates. The results showed that 87.5% of postgraduates knew that chronic HBV infection confers a high risk of cirrhosis, followed by the final year (63.7%) and then interns (58.8%), reflecting a statistically significant difference (P = 0.006). Overall, postgraduates were significantly more knowledgeable than final year and interns [Table 4].

Table 5 describes the correlation between independent variables (year of the study, HBV vaccination coverage, level of booster dose) and dependent variable (knowledge about the HBV Infection). A Spearman’s rank order was run to determine the relationship between the year of the study, HBV vaccination coverage, level of booster dose, and knowledge about the HBV. There was a strong, positive correlation between the year of the study, HBV vaccination coverage, level of a booster dose, and knowledge about HBV infection, which was statistically significant (r = 0.643, P = 0.39; r = 0.669, P = 0.35; r = 0.721, P = 0.20).

DISCUSSION

HBV is perhaps one of the most serious occupational hazards that dental workers can encounter. Previous research has found that percutaneous injuries among dental students are more common than among students in other professions of healthcare, and dental students are ranked sixth among high-risk professionals for HBV infection.^[13] The purpose of this study was to explore the level of knowledge, perspectives, and practice about HBV infection among dental students and postgraduates at a private dental college. The study assessed dental students’ knowledge of the HBV and vaccination, and 86% of the students received vaccinations in the current study. Vaccination rates among dental healthcare workers range from 33% to 97%, according to previous research across the world.^[14-17] The vaccination status in this study was higher than in previous investigations by Bansal et al.,^[18] where only 23.7% of the respondents were vaccinated, and Gayathri and Kumar^[19] in India, where only 62% reported being vaccinated. Most students in the vaccinated group completed all three doses of their vaccination regimen, while a small percentage of students were only partially vaccinated. Even though hepatitis B vaccination should be a top focus for this group, they are lacking in terms of vaccination. This study found that various factors, such as lack of information, inaccessibility, and ignorance, were linked to complete vaccination status, which was supported by the literature.^[20]

In the present study, knowledge of the HBV varied greatly across research participants depending on the year of the study. According to the survey findings, postgraduate dental students have a high level of knowledge regarding HBV (91.5% overall). Indeed, the fact that all the knowledge questions were answered correctly strengthens this notion. Furthermore, it was distressing to observe that final-year students and interns had less knowledge in this field, which was shown to be statistically insignificant with a P = 0.398. This can be justified by claiming that knowledge levels will improve by the time of graduation. This is consistent with the findings of Nagpal and Hedge,^[21] who found that 97.7% of individuals were aware of hepatitis. The graduating dental students reported less knowledge than postgraduates on hepatitis family history and said that there is no family history of hepatitis, which is a true answer. This supports the evidence,^[22] stating that hepatitis B is not genetic or inherited; it is only transmitted through direct contact with infected blood or sexual interaction; family members might be sick without knowing it.

In the current study, when the question “dentists are more prone to HBV infection” is asked, final years had less knowledge than interns and post-graduates, which is statistically insignificant with a P = 0.398. It was evident from this study that dental professionals are at an increased risk of infection with a variety of microbes, including HBV and HCV, herpes simplex virus, aids, mumps, measles, and rubella.^[23] This possible risk may be worsened by accidental harm during inpatient care,^[24] rotary-induced traumas, and needlestick injuries, which put dentists at a higher risk of HBV infection.^[25] The majority of research concluded that dental students were at higher risk of HBV exposure than other healthcare professionals, which agrees with our study findings.^[4] Despite the wide range of participants’ graduation levels, our study observed that overall knowledge of HBV and its method of transmission was high. This is like a study conducted by Sain et al.,^[26] and Kumar et al.,^[27] who also stated that 81.55% of the participants were aware of HBV transmission.

The current study reported that postgraduates had a higher knowledge score than interns and final-year students when it came to recognizing whether saliva is the source of hepatitis B transmission and reported that saliva is not a source of transmission for HBV. Most of the students were aware that hepatitis B is spread by contact with contaminated blood or bodily fluids. This is congruent with the findings of Khan et al.,^[28] who concluded that HBV transmission transpires through blood and fluid. In contrast, 72.6% of respondents in the Kurdistan area of Iraq^[29] reported that hepatitis B is transmitted by saliva. The present findings support the evidence that exposure to infected blood or body fluid, contaminated needles, contact with non-intact skin, or unsafe sexual contacts are risk factors for HBV infection.^[30] In dental practice, transmission takes place because of fluid exposures through cutaneous scratches, abrasions, burns, different lesions, or through direct or oblique touch with blood and/ or on mucosal surfaces, needle stick injury.^[7] Surprisingly, the gathered data revealed more significant results among the study participants in terms of hepatitis B viral complications. More than 70% of those respondents said that HBV may cause liver cirrhosis. This is consistent with the prior study’s findings.^[31] In terms of respondents’ knowledge about liver cancer, HBV was mentioned as a cause by 76.2%, with a statistically significant difference between study participants based on level of education. Kareem et al.^[29] observed a similar level of knowledge.

One of the study’s findings revealed that the year of the study, HBV vaccination coverage, and level of booster dose were positively correlated with knowledge scores; however, there was no significant association. This is consistent with the findings of the systematic review, which found that the higher the degree of education, the more likely a person was to have adequate knowledge and receive hepatitis B vaccination.^[32]

This study’s sample size and high response rate can be regarded as its merits. It is a questionnaire-based, cross-sectional study. As a result, a causal relationship cannot be established. The study’s findings are limited in their generalizability because the participants were drawn from only one institute. Because the closed-ended questionnaire could not reveal specifics about the participant’s knowledge, opinion bias cannot be ruled out.

CONCLUSION

According to the findings of the current study, the majority of participants are aware of HBV, its route of transmission, complications, and immunization. According to the findings of our study, undergraduate students had a lower knowledge of HBV infection than postgraduate students. This finding emphasizes the importance of conducting mandatory continuous health education courses among healthcare providers, including dental students, as well as utilizing social media to spread key messages about HBV transmission and prevention, in addition to standard educational courses for healthcare providers.