Knowledge, attitudes and practices of health care workers regarding hepatitis b vaccination, in the Ekurhuleni Metro, Gauteng Province




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Knowledge, attitudes and practices of health care workers regarding hepatitis B vaccination, in the Ekurhuleni Metro, Gauteng Province.


By


Patricia N. Africa

Student Number: 18701717

Project number: MREC/PH/212/2008: PG


Supervisor: Rosemary Burnett


Dissertation submitted to the School of Public Health, Faculty of Health Sciences, University of Limpopo, Medunsa Campus in partial fulfillment of the requirements for the degree Masters of Public Health.

Pretoria, 2009


DECLARATION


I, Patricia N. Africa, declare that this dissertation is my work. It is being submitted for the degree of Master of Public Health in the University of Limpopo, Medunsa Campus.

It has not been submitted before for any degree or any examination at this or any other University.


_____________________________________

Signature of candidate


_____________________________________

Date


The work presented in this dissertation was undertaken in the School of Public Health, Faculty of Health Sciences, University of Limpopo, Medunsa Campus.


ACKNOWLEDGEMENTS



A huge thank you to:

My mother Rosemary and my father, the late Cyril Africa, for a lifetime of love and support, and for instilling in me that great things come through perseverance; my husband, Dennis, for being there for me. Your presence has given me strength to grow and reach for the stars; my sons, Siyabonga and Mthokozisi, my girls, Nontobeko and Noxolo, for sharing me so often with my work and studies. Your unselfish love and support is God given; my supervisor, Rosemary Burnett, for all her help in making this study better than it started out; and to all my friends and colleagues for the encouragement, advice, and inspiration.


TABLE OF CONTENTS

COVER PAGE i

DECLARATION PAGE ii

ACKNOWLEDGEMENTS iii

TABLE OF CONTENTS iv

LIST OF TABLES viii

LIST OF FIGURES x

LIST OF ABBREVIATIONS AND ACRONYMS xi

LIST OF OPERATIONAL DEFINITION xii

ABSTRACT xiv

CHAPTER 1 Introduction 1

1.1 Background 1

1.2 Research questions 2

1.3 Study aim and Objectives 2

1.4 Rationale and problem statement 3

CHAPTER 2 Literature Review 4

2.1 Aetiology of Viral Hepatitis 4

2.2 Epidemiology of HBV 4

2.2.1 Virology of HBV 4

2.2.2 Transmission 5

2.2.3 Prevalence of Hepatitis B virus 6

2.2.4 Laboratory Diagnosis 7

2.2.4.1 Serological Markers 7

2.2.4.2 Biochemical Tests 9

2.2.5 Treatment 10

2.2.6 Prevention and control 11

2.2.6.1 General precautions in the health care setting 11

  • Screening of blood products 11

  • Injection safety 11

  • Universal precautions 12

  • Hepatitis B infected HCWs 13

2.2.6.2 Post exposure prophylaxis (PEP) 14

2.2.6.3 Vaccination programmes 15

2.3 Occupational HBV exposure 17

2.3.1 Introduction 17

2.3.2 Knowledge 17

2.3.2.1 Knowledge about occupational risks 17

2.3.2.2 Knowledge about the hepatitis B vaccine 18

2.3.3 Attitude 19

2.3.3.1 Attitudes towards universal precautions 19

2.3.3.2 Attitudes towards vaccination 19

2.3.4 Practice 21

2.3.4.1 Needle Stick Injury and Post Exposure Prophylaxis 21

2.3.4.2 Vaccination 22

2.4 Gaps in the literature that will be addressed by this study 23

CHAPTER 3 Research Methodology 25

3.1 Study design 25

3.2 Setting and site selection 25

3.3 Population/ Sample 25

3.4 Sample size calculation 25

3.5 Data collection Tool 27

3.6 Data collection methods 28

3.7 Data Analysis 29

3.8 Reliability and validity of the study 29

3.9 Bias 30

3.10 Ethical considerations 30

CHAPTER 4 Results 32

4.1 Response rate 32

4.2 Descriptive Statistics 32

4.2.1 Demographic profile of respondents 32

4.2.2 Knowledge about vaccination against hepatitis B 36

4.2.3 Attitudes of HCWs towards vaccination against HBV 38

4.2.4 Practices of HCWs regarding prevention of HBV 41

4.2.4.1 Vaccinated HCWs 41

4.2.4.2 Occupational exposure 42

4.3 Barriers to effective hepatitis B vaccination 43

CHAPTER 5: Discussion, conclusion, and recommendations 47

5.1 Discussion 47

5.1.1 Response rate 47

5.1.2 Knowledge 48

5.1.2 Attitude 49

5.1.3 Practice 50

5.1.4 Barriers to/ predictors for vaccinations of HCW 51

5.2 Conclusion 52

5.3 Recommendations 52


REFERENCES 54

APPENDICES 62

Annex A: Data collection tool 62

Annex B: Coding 67

Annex C: Invitation Letter 72

Annex E: Permission letters 73


LIST OF TABLES

Table 3.1: The relationship between population and sample size 27

Table 4.1: Frequency distribution of age of HCWs 33

Table 4.2: Frequency distribution of employment as HCW in years 34

Table 4.3: Frequency distribution of health care site 35

Table 4.4: Frequency distribution of knowledge scores 36

Table 4.5: Distribution of answers to knowledge 37

Table 4.6 Distribution of knowledge of HCWs 37

Table 4.7 Cross-tabulation between knowledge and being vaccinated 37

Table 4.8: Frequency distribution of attitude score 39

Table 4.9: Distribution of answers to attitude question 40

Table 4.10: Distribution of attitude of HCWs 40

Table 4.11: Cross-tabulation between attitude and being vaccinated 40

Table 4.12: Distribution of answers to protection against hepatitis B (n=161) 41

Table 4.13: Cross-tabulation of being vaccinated against hepatitis B with job

category 41

Table 4.14: Experiences of needle stick injury among HCWs (n=161) 42

Table 4.15: Binary Logistic Regression 44

Table 4.16: Comparing the mean scores for knowledge and attitude 44

Table 4.17: Cross-tabulation between knowledge scores and vaccination

against HBV 45

Table 4.18: Cross-tabulation between attitude score and vaccination against

HBV 45


Table 4.19: Cross-tabulation of race and being vaccinated against HBV 46

Table 4.20: Cross-tabulation of gender and being vaccinated against HBV 46

Table 4.21 Cross-tabulation of job and being vaccinated against HBV 46

Table 4.22 Cross-tabulation of duration as HCW and vaccination against HBV46


LIST OF FIGURES

Figure 2.1: The virus particle (Wikipedia) 5

Figure 2.2: Hepatitis B Prevalence (Wikipedia) 7

Figure 2.3: Hepatitis B Viral antigens and antibodies 9

Figure 4.1: Bar chart showing demographic characteristics of race 33

Figure 4.2: Bar chart for gender 34

Figure 4.3: Bar chart on Job category 35

Figure 4.4: Pie chart showing vaccine doses received 42

Figure 4.5: Experience of body fluids splashing among HCWs 43


LIST OF ABBREVIATIONS

Anti-HBs: Hepatitis B surface antibody

Anti-HBc: Hepatitis B core antibody

AIDS: Acquired immunodeficiency syndrome

BBV: Blood-borne viruses

CDC: Centers for Disease Control

DNA: Deoxyribonucleic acid

DTP: Diphtheria, tetanus and pertussis

EPI-SA: Expanded Programme on Immunisation-South Africa

FDA: Food and Drug Administration

HAV: Hepatitis A virus

HBV: Hepatitis B virus

HCV: Hepatitis C virus

HBeAg: Hepatitis B endogenous antigen

HBIG: HBV immune globulin

HBsAg: Hepatitis B surface antigen

HCW: Health care worker

HEI: Higher Educational Institutions

Hib: Haemophilus influenza type b

HIV: Human immunodeficiency virus

IV: Intravenous

NDoH: National Department of Health

PCR: Polymerase chain reaction

PEP: Post exposure prophylaxis

NSI: Needle sticks injury

PHC: Primary hepatocellular carcinoma

SAVIC: South African Vaccination and Immunisation Centre

SHEA: Society for Healthcare Epidemiology of America

WHO: World Health Organisation


LIST OF OPERATIONAL DEFINITIONS

Hepatitis B: A liver disease caused by the hepatitis B virus (HBV)

Acute hepatitis B: A new symptomatic HBV infection. Clinical symptoms and signs can include anorexia, malaise, nausea, vomiting, abdominal pains, and jaundice. Extra hepatic manifestations of the disease can also occur.

Antibody to hepatitis B surface antigen (anti-HBs): A positive result for this test means you have antibodies to HBV, and are protected against HBV. This may be due to a prior HBV infection from which one has recovered, or one may already have been vaccinated.

Antibody to hepatitis B core antigen (anti-HBc): A positive result for this test means you have been infected by HBV, either in the past or at present.

Blood borne virus: A viral infection that can be spread by contact with infected blood. The pathogens of primary concern are HIV, HBV, HCV and viral haemorrhagic fevers.

Chronic HBV infection: Carriage of HBsAg for longer than 6 months

Epitopes: Also known as antigenic determinant; it is the part of a molecule that is recognised by the immune system, specifically by antibodies, B cells, or T cells

Genotype: It is an organism’s full hereditary information, even if not expressed. The genotype represents its exact genetic make-up i.e. the particular set of genes it possesses

HBV carrier: A person with chronic HBV infection. The patient is potentially infectious, but may have no symptoms and no abnormalities on laboratory testing, or may have overt hepatitis or advanced liver disease.

HBV Serological marker: Antigens and antibodies associated with HBV infection include HBsAg and antibody to HBsAg (anti-HBs), anti-HBc, HBeAg and anti-HBe. At least one serologic marker is present during each of the different phases of HBV infection. They are typically used to differentiate between acute, resolving, and chronic infection.

Hepatitis B surface antigen (HBsAg): The outer surface of the virus. Testing positive for this antigen means you can easily pass the virus to others.


Icterus: Also known as jaundice, means a yellow pigment which is found in the blood and tissues. Any disease that causes destruction of liver cells or causes bile to become trapped in the liver can cause icterus, resulting in icteric disease

Immune-competent: An individual with a fully functional immune system

Immune-compromised: An individual with an improperly functioning immune system; a state in which the immune system’s ability to fight infectious disease is compromised or entirely absent

Liver cirrhosis: A consequence of chronic liver disease characterised by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules, leading to progressive loss of liver function.

Non-responder: A person who does not produce a protective antibody response to a primary 3-dose vaccine series, with anti-HBs concentrations of <10mIU/ml measured 1 month after the last dose.

Phenotype: It is an organism’s actual observed properties, such as morphology, development, or behaviour

Primary Hepatocellular carcinoma: A fatal malignancy of the liver most closely linked to chronic hepatitis B virus infection and liver cirrhosis.

Responder: A person who produces a protective antibody response to a primary 3-dose vaccine series, with anti-HBs concentrations of ≥10mIU/ml measured 1 month after the last dose.

Serotype: Is a group of micro organisms or viruses classified together based on their cell surface antigens. Serotypes allow the epidemiologic classification of organisms to the sub-species level

Universal precautions: They are deliberate actions taken in health care settings to prevent the transmission of certain pathogens (especially BBV) from patient to patient, from patient to HCW and from HCW to patient


ABSTRACT

Introduction: Hepatitis B is a serious liver disease caused by the hepatitis B virus (HBV), with an estimated 360 million chronic infections worldwide, about a million of which die each year from chronic liver diseases. In South Africa (SA) over 50% of the population has been infected by HBV, and at least 3 million people are chronic HBV carriers. Chronic HBV carriers have the potential of transmitting HBV parenterally in the hospital setting, thus health care workers (HCWs) are at risk of contracting HBV, with the most likely exposure being via a needle stick injury (NSI). There is an effective vaccine against HBV which is recommended by the SA Department of Health, yet previous studies have shown that most HCWs are not vaccinated.

Aim and objectives: The study aimed to investigate the knowledge, attitudes and practices regarding hepatitis B vaccination amongst HCWs in the Ekurhuleni Metro. Objectives were to determine: (1) the level of knowledge of HCWs about vaccination against HBV; (2) the attitudes of HCWs towards vaccination against HBV; (3) the practices of HCWs regarding HBV prevention and (4) the barriers to / predictors for effective HBV vaccination among HCWs at Ekurhuleni Metro

Materials and Methods: This was a cross-sectional descriptive study which made use of a self-administered questionnaire that was sent to Ekurhuleni nurses and doctors who were working in 3 public hospitals, 7 district clinics, and 110 general practices.

Results: Two hundred and fifteen questionnaires were distributed and 161 were returned giving an overall response rate of 74.9%. HCWs do not report their NSI; over a third [37.6% (41/81)] always reported the NSI; while 72% (116/161) of HCWs had been vaccinated, only 61.2% (71/116) of those vaccinated had received all 3 doses of the vaccine.

For knowledge of HBV vaccination, 66.5% (107/161) scored poor; 31.7% (51/161) scored moderate; and 1.8% (3/161) scored high. For attitudes towards HBV vaccination, 0.6% (1/160) scored negative; 24.4% (39/160) scored neutral; and 74.5% (120/160) scored positive. A positive attitude score was a significant predictor for being vaccinated (OR=1.13, p=0.007)

Conclusion: Guidelines should be put in place to increase vaccination uptake and reduce the risk of exposure to HBV infection by HCWs.


CHAPTER 1 INTRODUCTION

1.1 Background


Hepatitis B is a disease caused by the hepatitis B virus (HBV), which is transmitted through percutaneous or mucosal exposure to infectious blood or body fluids (Center for Disease Control [CDC], 2006). It is a major problem because it can cause chronic infection, resulting in cirrhosis of the liver, liver cancer, liver failure, and death. In addition, several extra-hepatic lesions occur because of HBV infection, with this, there is deposition of immune complexes in different organs of the body especially, the kidney (Koff R, 1991). Persons with chronic infection also serve as the main reservoir for continued HBV transmission (CDC, 2006).

HBV accounts for an estimated 360 million chronic infections (World Health Organisation [WHO], 2006) with about a million who die each year from chronic liver diseases (South African Vaccination and Immunisation Centre [SAVIC], 2008). Most persons who become chronic carriers of the virus live in Asia and Africa (Breining Institute, 2006). These regions are said to be highly endemic for hepatitis B. In South Africa (SA), over 50% of the population have been infected by the virus, and at least 3 million people are chronic HBV carriers (SAVIC, 2008).


The major route of HBV transmission in sub-Saharan Africa is horizontal (i.e. transmission unrelated to recognised sexual, perinatal, or parenteral exposure) (Davies et al, 1989) in children under 5 years of age; however, percutaneous/ parenteral transmission is also an important mode of spread (Hollinger, 2001).


Health care workers (HCWs) may be exposed to the risk of infection with blood-borne viruses (BBVs) such as HBV, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) via contact with blood (and other body fluids) in the course of their work (Kermode et al, 2005). The form of exposure most likely to result in occupational BBV infection is a needle stick injury (NSI).


HBV can be prevented by strict adherence to standard microbiological practices and techniques, and routine use of appropriate barrier precautions to prevent skin and mucous membrane exposure when handling blood and other body fluids of all patients in health care settings (SAVIC, 2008). Following exposure to blood or body fluids, post-exposure prophylaxis can be administered as a combination of passive immunization with hepatitis B immunoglobulin (HBIG) and vaccination with the hepatitis B vaccine (SAVIC, 2008). However, the most cost-effective method to prevent and control hepatitis B is through pre-exposure vaccination (SAVIC, 2008).


It is important for HCWs to know their HBV status by being screened for the HBV surface antigen (HBsAg) and antibody (anti-HBs), and to be vaccinated against hepatitis B if found to be unprotected. This will protect them from being infected, and prevent them from spreading the virus which can infect patients. The vaccine has been found to be safe and effective, and can protect one for a lifetime (SAVIC, 2008). Education and prevention of infection with HBV should be emphasized, and all patients should be regarded as potential HBV carriers regardless of their medical history or condition.

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