HEPATITIS B VACCINATION STATUS AND NEEDLE STICK INJURY EXPOSURE AMONG OPERATING ROOM STAFF IN LAGOS, NIGERIA

Abstract

Background

Hepatitis B virus (HBV) is an infective blood-borne pathogen that is a constant threat to operating room staff. The prevalence of Hepatitis B has been reported to range from 4.3% - 68% in Nigeria. The inadequate funding of health care in low income countries impacts negatively on the implementation of effective vaccination programs to protect health care workers including surgical theatre personnel.

Aim

To determine the Hepatitis B vaccination status and the needle stick injury exposure among operating room staff in Lagos, Nigeria.

Methodology

The multicentre prospective survey was conducted in three public tertiary hospitals and two private hospitals in Lagos utilising a self-administered structured questionnaire that was distributed to operating room staff.

Results

We found that 96.7% (265) of respondents agreed that their job had exposed them to the risk of HBV infection. Over half (55.8%) correctly identified three doses of HBV as adequate to confer immunity against infection. It was observed that 58% (159) of the respondents were fully vaccinated, most of whom were doctors (69.8%, p=0.001) while a total of 173 (63.1%) reported exposure to needle-stick injury with blood in the preceding year.

Conclusion

The operating room personnel were knowledgeable about the risk of HBV as an occupational hazard but a large number were not fully vaccinated against HBV infection. There was therefore the need to improve the vaccination coverage and educate identified high-risk operating room staff on appropriate post exposure prophylaxis practices.

Introduction

Hepatitis B (HBV) is an infective blood-borne pathogen that is a constant threat to operating room personnel. The prevalence of Hepatitis B has been reported to range from 4.3% - 68% in Nigeria1,2,3. The operating room staff are at increased risk from frequent contact with blood and needle stick injuries. Needle stick injuries occurs when there is accidental percutaneous injury by an injection needle that may result in exposure to blood or other body fluids4,5.

The adoption of Universal precautions and the availability of Hepatitis B vaccination led to a reduction of infections worldwide6,7,8. The recommended vaccination is a three-dose regimen with a second and third dose given at one and six months after the initial dose9,10. The World Health Organization recommended the integration of Hepatitis B vaccine into the national immunization program of all countries. Over 177 countries have national programmes that are mostly population wide with some target based11. The inadequate funding of health care in low income countries impacts negatively on the implementation of effective vaccination programs to protect health care workers including surgical theatre personnel. Ansa et al12 had reported the poor availability and improper use of hygienic and protective equipment by health care workers in South Eastern Nigeria.

We aim to determine the Hepatitis B vaccination status and the needle injury exposure in Lagos, Nigeria.

Patients & Methods

This prospective multicentre survey was conducted in Lagos in these three tertiary hospitals, Lagos University Teaching Hospital (LUTH), Lagos State University Teaching Hospital (LASUTH), National Orthopaedic Hospital (NOH), Igbobi, and two private hospitals in Lagos, R Jolad Hospital and Topaz Hospital. Research and Ethics Committee approval was obtained.

An anonymous self-administered structured questionnaire was distributed to operating room personnel after informed consent. The operating room personnel must have worked for at least one year to qualify to be included; those who had worked for less than one year in the operating theatre were excluded. There was no incentive for respondents.

The questionnaire sought information on demographics, knowledge about HBV infection, immunization status, barriers to immunization, needle stick injury and post exposure prophylaxis.

Data analysis was done with SPSS version 14 utilising descriptive statistics of frequency and percentages. Tests of association were done using Fishers’s exact test. The level of significance was set at p<0.05.

Results

A total of three hundred and forty questionnaires were distributed, out of which 274 were returned giving a response rate of 80.6%.

Their age ranged from x –y years with a mean age of 36.6±8.8 years while 152 (54.5%) were males and 122 (44.5%) were females with a male:female ratio of 1:1.25. The professional groups were made up of 166(60.6%) medical doctors, 56(20.4%) nurses, 35(12.8%) anaesthetic technicians and 17(6.2%) hospital porters (Table1).

In all, 265(96.7%) respondents agreed that their job exposed them to the risk of HBV infection while more than half of the respondents (55.8%) correctly identified three doses of HBV as adequate to confer immunity against infection (Table 2).

However, 159(58.0%) respondents were fully immunised (Table 3) while the others attributed reasons for non-immunization as busy schedules in 113(71.1%) respondents; ignorance of vaccination stations in 29(18.2%); vaccine was expensive in14 (8.8%) 3(1.9%) respondents felt the vaccine was unsafe.

Out of 173 (63.1%) respondents who admitted to have had needle stick injury in the preceding year, 122 (73.5%) were doctors but only 16 (9.6%) had received post exposure prophylaxis for HBV (Table 4).

Table 1. Demographics of the respondents.

	n (%)
Gender
Male	152(54.5)
Female	122(44.5)
Professional groups
Doctors	166(60.6)
Nurses	56(20.4)
Anaesthetic technicians	35(12.8%)
Hospital porter	17(6.2%)

Table 2. Knowledge and perceptions regarding Hepatitis B.

Does your job expose you to risk of hepatitis B infection			n (%)
Doctors	Y-166	N- 0	166 (62.6)
Nurses	Y- 54	N- 2	54 (20.4)
Anaesthetic technicians	Y- 34	N-1	34 (12.8)
Hospital porter	Y- 11	N-6	11 (4.2)
How many vaccine doses confer immunity
1			28 (10.2)
2			22 (8.2)
3			153(55.8)
>3			16 ( 5.8)
Don’t know			55 (20.1)
Y-Yes N-No

Table 3. Hepatitis B vaccination among professional groups in the operating rooms.

Table 3:
Hepatitis vaccination status	n (%)	X2, df (p value)
Vaccinated	159(58.0)
Not vaccinated	115(42.0)
Occupation of vaccinated
Doctors	111(69.8)	37.814,9(p=0.001)
Nurses	42(26.4)
Anaesthetic technicians	4(2.5)
Hospital porter	2(1.3)
Reasons for incomplete vaccination
Busy Schedule	113(71.1)
Ignorance of vaccination point	29(18.2)
Vaccine was found to be expensive	14(8.8)
Vaccine suspected to be unsafe	3(1.9)

Table 4. Needle stick Injury and post exposure prophylaxis.

Have you had a blood stained needle stick injury in the past one year	n (%)	X2,df (p value)
Yes	173(63.1)
No	101(36.9)
Distribution of needle stick injury among occupational groups
Doctors	122(70.5)	16.417,3(p=001)
Nurses	44(25.4)
Anaesthetic technicians	5 (2.9)
Hospital porter	2 (1.2)
Post exposure prophylaxis
Yes	16 (9.6)
No	157(90.4)

Discussion

This study found a high level of awareness among operation room personnel with regard to HBV exposure which is similar to the findings of Okwara et al13 who observed that 94% of health care workers were aware of Hepatitis B Virus risk. The study done by Ibekwe et al14 found that 50% of health care workers were aware of Hepatitis B Virus. We found 58.0% of respondents had complete vaccination status comparable to findings by Fatusi et al15 who reported a similar proportion of complete vaccination of 53.8%. However findings by other investigators in Nigeria had revealed a much higher proportion of incomplete immunisation between 73%-96% of study population14,16,17. These differences may have likely occurred as result of varying institutional focus on awareness, availability and cost of the vaccines. We observed in our study that majority attributed their non-immune status to busy schedules and may reflect that this important intervention to reduce Hepatitis B Virus infection is left entirely to the discretion of operating room staff.

There had been several studies that have demonstrated that the acceptance of Hepatitis B vaccine and compliance to established vaccination regimes have been found to depend on knowledge of vaccine, easy availability, perception of risk, fear of side effects18,19,20,21,22. Majority of our respondents are doctors and nurses who are higher cadre of health care workers functioning at a tertiary level of care with relevant knowledge that may have positively impacted on their perception and attitudes to immunization. There was a report of higher coverage level of Hepatitis B Virus by Simard et al23 in the United States but a recent review of vaccine preventable diseases covering Europe revealed varied levels of coverage with significant immunity gaps among health care workers with regard to vaccine preventable blood pathogens18.

This study observed that 63.1% of respondents had needle stick injury, 9.8% of whom benefited from post exposure prophylaxis which is comparable to the findings of Ibekwe et al11 who reported that out of 53.7% of respondents who had needle stick injury none received post exposure prophylaxis.

The world health organization (WHO) had reported over two billion people infected with the HBV including over 240 million who showed clinical evidence of HBV infection. There are more than 600,000 deaths per year due to complications of HBV, including cirrhosis and Liver cancer. Thus it is recognized as an important occupational hazard for health care workers24.

An effective vaccine against HBV has been available since 1982. It is widely accepted as a safe and effective vaccine. The recommended vaccination schedule is a 3-dose regimen with an interval of one month between the 1^st and 2^nd dose, while a six month interval is observed between the 2^nd and 3^rd dose. It is recommended that a post vaccination test for Hepatitis B surface antibody should be done on completion of the vaccination schedule25.

Overall we found that operating room personnel were knowledgeable about the risk of HBV as an occupational hazard in the operating room; however a large number were not fully vaccinated against HBV infection. Participants need to improve their attitudes toward HBV immunization. Post exposure prophylaxis was not a routine practice.

There is a need to improve the vaccination coverage and educate identified high-risk operating room staff on appropriate post exposure prophylaxis practices in order to improve the prevention of HBV infection among operating room staff. There is an ethical imperative for health care workers to be immune and for health care institutions to ensure HBV vaccination in high-risk groups. We need to balance patients’ welfare and public health concerns with the individual autonomy of operating room staff. Consequently, acceptable institutional based mandatory vaccination policies may be considered for the good of all concerned. Institutions should consider the option of pre-employment vaccination of operating room staff to improve vaccination coverage.

The study was limited, as it did not determine whether protective levels of anti HB surface antigen were present in vaccinated respondents. There was also the possibility of self-reported questionnaire bias.

Conclusions

The operating room personnel were knowledgeable about the risk of HBV as an occupational hazard but a large number were not fully vaccinated against HBV infection. There was therefore the need to improve the vaccination coverage and educate identified high-risk operating room staff on appropriate post exposure prophylaxis practices.