|Year : 2017 | Volume
| Issue : 1 | Page : 3-8
Hepatitis B: Knowledge and attitude of graduating dentists from faculty of dentistry, Sebha University, Libya
Syed Wali Peeran1, Syed Ali Peeran2, Marei Hamad Al Mugrabi3, Khaled Awidat Abdalla4, Manohar Murugan5, Fatma Mojtaba Alsaid6
1 Department of Periodontology and Oral Implantology, Faculty of Dentistry, Sebha University, Sebha, Libya
2 Department of Prosthodontics, Faculty of Dentistry, Jizan University, Jazan, Saudi Arabia
3 Department of Periodontics, University of Benghazi, Benghazi, Libya
4 Department of Oral Biology and Orthodontics, Faculty of Dentistry, Sebha University, Sebha, Libya
5 Department of Microbiology, Faculty of Medicine, Sebha University, Sebha, Libya
6 Department of Periodontics, Faculty of Dentistry, Sebha University, Sebha, Libya
|Date of Web Publication||20-Jan-2017|
Syed Wali Peeran
Department of Periodontology and Oral Implantology, Faculty of Dentistry, Sebha University, Sebha
Source of Support: None, Conflict of Interest: None
Background: Hepatitis B virus (HBV) is a major worldwide cause of acute and chronic liver infection. Dentists, dental students, and their paramedical staff are at a heightened risk of exposure to HBV. Aim: The aim of this study was to assess the knowledge and attitude of the graduating dentist from Faculty of Dentistry, Sebha University (Libya), toward hepatitis B infection. Subjects and Methods: Ninety-nine participants completed the self-administered, structured, pilot-tested close-ended 37-item questionnaire. Results: It was found that the graduating dental students from different study years have similar knowledge and attitude, except for the responses to questions on curriculum, contracting hepatitis B virus (HBV) from patient, vaccination schedule, perception, and treatment modality for HBV-infected patient, where statistically significant difference was noted. Conclusion: The results indicate that there is need to spread greater awareness about risk and seriousness of the HBV infection among the graduating dentists. We recommend that the dental policymaker considers modifying the dental curriculum to include a detailed session of training in areas of universal infection control procedures, handling high-risk patients, combating fear while treating patients, and teaching them to avoid discriminatory behavior beginning in the 3rd year itself.
Keywords: Hepatitis B, Libya, Sebha, student attitudes
|How to cite this article:|
Peeran SW, Peeran SA, Al Mugrabi MH, Abdalla KA, Murugan M, Alsaid FM. Hepatitis B: Knowledge and attitude of graduating dentists from faculty of dentistry, Sebha University, Libya. Dent Med Res 2017;5:3-8
|How to cite this URL:|
Peeran SW, Peeran SA, Al Mugrabi MH, Abdalla KA, Murugan M, Alsaid FM. Hepatitis B: Knowledge and attitude of graduating dentists from faculty of dentistry, Sebha University, Libya. Dent Med Res [serial online] 2017 [cited 2017 Oct 20];5:3-8. Available from: http://www.dmrjournal.org/text.asp?2017/5/1/3/198785
| Introduction|| |
Hepatitis B virus (HBV) is a major worldwide cause of acute and chronic liver infection. Nearly, two billion people in the world are acutely infected by HBV and another 350 million people chronically infected. Of these, at least one million people die annually from HBV-related chronic liver disease, including cirrhosis, primary hepatocellular carcinoma, and liver cancer.
Worse, 75% of these cases hail from the Asian continent where an estimated 8% and 15% are suspected to be active carriers of this virulent virus. Nearly, 80% of the infections are subclinical which means that their disease remains undiagnosed. In this latent form, HBV is potentially 50–100 times more infectious than HIV.
Dentists, dental students, and their paramedical staff are at a heightened risk of exposure to HBV primarily because dentistry involves extensive and intensive use of small, sharp instruments that can easily get contaminated with infected blood, during an invasive procedure, which is the main mode of transmission of HBV. The past studies indicate that the risk of exposure for general dentists is about 3–4 times greater, and for nonimmunized surgical specialists, about 6 times greater than that of the general population (Polakoff and Tillett, 1984).
This occupational hazard can be controlled to a major extent with the extensive use of HBV vaccination and the recommended use of protective gear, such as gloves to check blood-borne infection transmission during dental procedures (Ammon et al., 2000). The HBV is easily available since 1982 and has been recommended for healthcare workers whose activities frequently expose them to contaminated blood products.
In 2003, the Center for Disease Control and Prevention in the United States of America updated their guidelines for infection control in dental settings. This includes, but is not limited to, wearing a face mask, eye protection, protective clothing, and other cautionary materials that can be laundered in an in-house laundry. Awareness and compliance with these recommendations are very important for the prevention of occupational and contagious infections in healthcare workers, especially for protecting dental healthcare workers.
Unfortunately, even dental students do not always conform to these practices, leading to greater risk to themselves and their patients. A study done in the Dentistry Department of Ankara University in Turkey  had revealed moderate adherence to standard infection control precautions among dental clinical students.
Since graduating dental students go on to make the future dental healthcare providers, there is an urgent need to make them aware of the risk of spreading and catching contagions such as the HBV, during the interaction with their patients. The aim of this study was to assess the knowledge and attitude of the graduating dentist toward hepatitis B infection.
| Materials and Methods|| |
The study design was a cross-sectional survey using a self-administered, structured, pilot-tested closed-ended 37-item questionnaire. The study was conducted among the graduating dentists (3rd year, 4th year, and interns) from the Faculty of Dentistry, Sebha University (Libya). In the questionnaire, under knowledge section, four domains were identified: General information (Q.1–3), transmission (Q.4–10), vaccination (Q.11–15), and symptoms of hepatitis B (Q.16). Under the attitude section, two domains were identified: Perception toward hepatitis B patients (Q.17–28) and treatment modality (Q.29–37). The survey instrument was pilot tested on 20 dental students and revised according to their feedback. Fifty percent of the total strength of the students from 3rd-year students to interns in the dental course was recruited into the study. The sample was randomly selected. The proposal was approved by the Ethics Committee of the Institution. Written informed consent was obtained from the study participants.
The questionnaire was distributed to the students in their respective classrooms and 25 min of time was given to them to fill it out. The forms were collected and checked for completeness, and the doubts (if any) were cleared. The data were entered into MS Excel and analyzed using the Statistical Package for Social Sciences (SPSS) software 16.0 version (SPSS Inc., US). Descriptive statistics including frequencies and percentages were calculated, and the comparison between the participants as per their study year was done using Chi-square test. The level of significance was set at 5%.
| Results|| |
There were 99 study participants (aged 20–23 years old). Forty-one were 3rd-year students, 31 were from final year students, and 27 were interns. There were 24 males and 75 females. The results are presented in two tables.
[Table 1] depicts comparative results of the responses to the knowledge-based questions. Majority (54%) admitted to inadequate knowledge of the HBV subject (Q.1), and when probed further, only 29.0% of 4th-year students, 41.5% of 3rd-year students, while 63.0% of interns felt that their curriculum did justice to make them fit to manage the HBV-infected patients (Q.2). Nearly, maximum respondents from the three categories gathered their primary information (Q.3) on HBV from books, followed by visual media and others. Majority (70%) felt that injection use, blood transfusion, hemodialysis, organ transplantation, and sexual intercourse are the transmission routes for the HBV (Q.4).
|Table 1: Distribution and comparison of the participant's knowledge about the various aspects related to hepatitis-B virus|
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Interestingly, while the variance in response to Q.5 on patient-to-dentist transmission of HBV was significant (P = 0.004), there was no much difference in threat perception relating to dentist-to-patient transmission of the virus (Q.6). In the first case, while a significant percentage of 4th-year students and interns perceived the threat of dentist-to-patient transmission as high, a much smaller proportion of 3rd-year students felt that this risk was high. Further, their responses on questions related to transmission and vaccination (Q.7–14) matched; however, on the question of the correct timing for booster dose administration (Q.15), the P value was statistically significant (0.04), indicating that there is considerable knowledge gap among the dental students. Overall, 52% felt that chronic hepatitis, cirrhosis, liver cancer, jaundice, and death are caused by HBV. However, 37% and 34%, respectively, felt that HBV can cause alone cirrhosis and chronic hepatitis (Q.16).
[Table 2] depicts comparative results of the responses to the attitude-based questions. In the attitude section, the difference in response was significant on Q.17, 19, betraying their fear of treating an HBV patient in a clinical set-up and providing treatment with standard precautions taken. The fear appeared to be acute in 3rd-year dental students in comparison to interns and 4th-year students (Q.17). However, there was no significant difference of opinion on whether the HBV-infected person should be allowed to study in the dental college (Q.18). The difference in response was significant to Q.20–22 (about treating patients with HBV), with the 3rd-year students least wary and willing to treat them. About the ethical and moral responsibility of a dentist to treat a hepatitis B patient (Q.23) and the need to take special precautions (Q.24), there was no significant difference in the responses of the three cohorts. A higher proportion of interns (92.6%), than 4th-year students (74.2%) and a much lesser percentage of 3rd-year students (63.4%), thought that the infected patients were ethically bound to declare their HBV status to their treating dentist (Q.25). The difference in response was statistically significant (P = 0.025).
|Table 2: Distribution and comparison of the participant's attitude about the various aspects related to hepatitis-B virus|
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However, when this point was probed further (Q.26, 27), the variance in their response was insignificant. About mandatory screening of all patients for hepatitis B (Q.28), risk to the dentists (Q.29), regular and periodic screening of all dental care workers (Q.30), mandatory testing of all patients before a surgical procedure (Q.31), and the threat of spreading fear among the dental care workers if a patient's hepatitis B status is made known (Q.32) – the responses did not differ significantly among the three groups. Questioned on the right to reject treating the HBV patients (Q.33), a higher majority of 3rd-year dental students (56.1%) thought that this would be the correct approach than 4th-year (32.3%) students and interns (26.9%). The responses on Q.34, 36, and 37 matched among the three groups. At last, on Q.35 (mouth resuscitation in an emergency situation), more interns (18.5%) than 4th-year (38.7%) and 3rd-year students (51.2%) appeared willing to offer mouth to mouth resuscitation to a hepatitis B suspect.
| Discussion|| |
This questionnaire study assessed the knowledge (which included general information, transmission, vaccination, and symptoms) and attitude (which included perception toward hepatitis B patients and treatment modality) of the graduating dentist from the Faculty of Dentistry, Sebha University (Libya), toward hepatitis B infection.
From the elaborate explanation of the comparative results in the preceding section, it appears that graduating dental students from different study years have similar knowledge and attitude except for the responses to Q.1, 2 (general information), Q.5 (transmission), Q.15 (vaccination), Q.17, 19–22, Q.25, (perception toward hepatitis B patients), and Q.33, 35 (treatment modality), where statistically significant differences have been noted.
In context to the general information, larger percentage of 3rd-year students feel that they have inadequate knowledge about HBV infection (Q.1) and greater percentage of third and final years feel that the current curriculum will not make them fit to manage patients with hepatitis B (Q.2). The dental governing body should take a note of this and bring about change in the curriculum which will provide greater emphasis on training the dental students to handle high-risk patients.
With regard to the transmission of HBV, greater percentage of 3rd-year students feel that the dentist can contract hepatitis B from his patients if he/she does not use proper barrier techniques (Q.5). Over a 4-year period in a five-county area in the US, 71 patients with clinical hepatitis B had dental work performed in the 2–6 months before their illness (Rimland et al. 1977). Fifty-five cases were traced to a single oral surgeon. Seventy-nine percent of these patients were discovered to be positive for hepatitis B surface antigen (HBsAg) with no other recognized source of hepatitis. An investigation of the implicated dentist uncovered no gross inadequacies in instrument sterilization or general dental procedures; however, the dentist was found to be an asymptomatic carrier of HBsAg of the same subtype (ay) as nine of 11 of his/her patients who had hepatitis and whose serums were available for testing. Till date, this remains one of the most alarming cases of medical negligence and dentist-to-patient transmission of hepatitis B on such a wide scale. It rang alarm bells across the fraternity, all over the world.
However, till date, vaccination remains as the lone mode for preventing the spread/contracting the HBV. In the present study, very few 3rd-year students knew about the correct schedule of the booster dose (Q15). A survey  among Jordanian Dental College students showed that about 90% of them were aware of the existence of the vaccination against hepatitis B and nearly 50% of the respondents had already inoculated themselves. In contrast, a postal survey of 730 Malaysian dental practitioners  indicated that only 32% of the 325 respondents had been vaccinated, 41% wanted to be vaccinated, and 15% categorically refused vaccination out of unfounded fears of side effects including the threat of developing AIDS, cost of the vaccine, and such. Similarly, a report from a recent Indian study  among 1st- and 2nd-year dental students at a private dental institution found that bulk of the student respondents had sought immunization against HBV, and only 59.7% were actually aware of the root cause and effect of HBV.
Although general awareness about hepatitis-B vaccination has increased significantly over the years, the dental students need to be made more aware of the necessity to be vaccinated and the vaccine schedule. They must be made aware through their curriculum that because of the nature of their work, and the high prevalence of this disease, they are constantly in danger of getting HBV infection and can also, simultaneously pose a threat to their patients.
The present study result indicates that maximum 3rd-year students refused to treat hepatitis B positive patient in a normal dental setting (Q.17). Greater percentage of interns and 3rd years felt confident with the standard precautions taken that there will be no transmission of HBV (Q.19). Greater percentage of interns has treated a hepatitis B positive patient knowingly (Q.20); 3rd-year and final year students did not want to treat patients, who are at high risk of hepatitis B such as injecting drug users (Q.21); interns and final years would be stressed while treating a known case of hepatitis B-positive patient or the risk groups (Q.22.). During the dental course, the 3rd-year students are apparently new at providing clinical treatment. They have still not gained full exposure of handling different medical cases and face ethical challenges. Their attitudes are shaped more by the prevailing myths, possibly gathered from mass media channels. Comparatively, the final years and interns have more exposure and experience and in turn reflect in their positive attitude toward patient carriers of hepatitis B and their willingness to treat them in their dental facility after taking adequate precautions. This difference can be attributed to the fact that as the students graduate to higher levels in their study and practice of dental science, myth perhaps gets gradually replaced by fact and they start overcoming their fear of the virus, while also understanding the need to take adequate precautions. A study in Puducherry  compared hepatitis-B awareness among medical and dental interns to reveal that one-third of the interns had very good knowledge about the risk factors associated with hepatitis B spread. However, there were misconceptions related to prophylaxis, vaccination, and treatment of HBV.
In the present study, it was observed that the interns and final years felt that the patient should inform them correctly about his hepatitis B-positive status (Q.25). However, many a times, the patients are unaware of exposure to HBV. Regardless of the medical history, all patients should therefore be regarded as potential HBV carriers, and hence, proper infection control protocol should be followed for every patient. The dental students face a serious occupational risk in acquiring hepatitis B infection during their clinical practice is supported by a Brazilian study, where it was found that the prevalence of percutaneous injuries was 59.8% among dental practitioners. These risks can be confined with careful adherence to recommended infection control protocol, including the use of protective barriers methods of sterilization or disinfection. However, a self-administered, questionnaire-based study  in India among dental students found that although dental students' attitude toward infection control measures was positive, they still needed to be warned about the repercussions of noncompliance with the recommended safety protocol.
While in a circumstance of providing treatment to the HBV-positive patient, the 3rd-year study participants felt that the dentist/healthcare provider has the right to reject treating a hepatitis B-positive patient (Q.33) and in case of an emergency they will not be ready to perform mouth to mouth resuscitation for a hepatitis B-positive patient (Q.35). Dentist should not have a discriminatory approach toward the HBV-infected persons and follow proper infection control measures while treating such cases. An exhaustive qualitative survey of British dentists  gives deep insights into the reasons for the persistence of prejudices toward treating high-risk groups among dental practitioners and emphasizes the need to probe this area further. Tibdewal et al. have emphasized on the declaration of a national policy on protecting dental practitioners from infectious hazards. They suggested an aggressive approach in making the vaccination available, along with comprehensive health and disability insurance. Such policy measure, it is believed would combat the fear element in the dental college students and positively change their attitude to hepatitis B patients.
| Conclusion|| |
The results of this study indicate that there is need to spread greater awareness among the graduating dentist about hepatitis-B infection. They have to be made aware of the risk and seriousness of the infection. We recommend that the dental policymaker considers modifying the dental curriculum to include a detailed session beginning in the 3rd year itself to make the graduating dental students:
- Knowledgeable in topics related to HBV and all other infectious diseases
- Second, instruct them to follow universal infection control procedures for every patient irrespective of the HBV carrier status
- Third, train them how to handle the high-risk patients in the dental clinic, combat their fear, and teach them to avoid discriminatory behavior against the high-risk patients
- Fourth, make strict guidelines of infection control procedures to be followed in the college and appoint a surveillance officer to check whether every dental student is vaccinated before he/she is admitted to the 3rd year
- Finally, conduct a continuing dental education program every year to keep them abreast of the latest information.
We wish to thank the Medilinkers Research consultancy for providing help in statistical analysis and editing the paper for English language.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hadler SC. Global impact of hepatitis A virus infection. In: Hollinger BF, Lemon SM, Margolis HS, editors. Proceedings of the 1990 International Symposium on Viral Hepatitis and Liver Diseases: Viral Hepatitis and Liver Disease. Vol. 14. Baltimore: Williams & Wilkins; 1991. p. 94-7.
Goebel WM. Reliability of the medical history in identifying patients likely to place dentists at an increased hepatitis risk. J Am Dent Assoc 1979;98:907-13.
Arya SC, Ashraf SJ, Parande CM, el-Sayed M, Sahay R, Ageel AR, et al.
Hepatitis B virus in Gizan, Saudi Arabia. J Med Virol 1985;17:267-74.
Polakoff S, Tillett HE. Acute viral hepatitis B: Laboratory reports 1975-9. Br Dent J (Clin Res Ed) 1982;284:1881-2.
Ammon A, Reichart PA, Pauli G, Petersen LR. Hepatitis B and C among Berlin dental personnel: Incidence, risk factors, and effectiveness of barrier prevention measures. Epidemiol Infect 2000;125:407-13.
Van Damme P, Van Herck K. A review of the long-term protection after hepatitis A and B vaccination. Travel Med Infect Dis 2007;5:79-84.
Askarian M, Assadian O. Infection control practices among dental professionals in Shiraz Dentistry School, Iran. Arch Iran Med 2009;12:48-51.
Leggat PA, Kedjarune U, Smith DR. Occupational health problems in modern dentistry: A review. Ind Health 2007;45:611-21.
Abreu MH, Lopes-Terra MC, Braz LF, Rímulo AL, Paiva SM, Pordeus IA. Attitudes and behavior of dental students concerning infection control rules: A study with a10-year interval. Braz Dent J 2009;20:221-5.
Akbulut N, Öztaş B, Kurşun S, Çölok G. Knowledge, attitude and behaviour regarding hepatitis B and infection control in dental clinical students. Clin Dent Res 2012;35:21-7.
Rimland D, Parkin WE, Miller GB Jr., Schrack WD. Hepatitis B outbreak traced to an oral surgeon. N Engl J Med 1977;296:953-8.
Scully C, Bakaeen G, Levers H. Hepatitis B vaccination and infection control practices of Jordanian clinical dental students. J Oral Pathol Med 1991;20:350-1.
Yaacob HB, Samaranayake LP. Awareness and acceptance of the hepatitis B vaccine by dental practitioners in Malaysia. J Oral Pathol Med 1989;18:236-9.
Holenarasipur VA, D'Cruz MA. Awareness regarding hepatitis B immunization among preclinical Indian dental students. J Oral Health Oral Epidemiol 2013;2:97-101.
Tirounilacandin P, Krishnaraj S, Chakravarthy K. Hepatitis-B infection: Awareness among medical, dental interns in India. Ann Trop Med Public Health 2009;2:33-6.
Reddy SR, Swapna LA, Ramesh T, Pradeep K. Knowledge, attitude and practice on hepatitis B prevention among dental professionals in India. Braz J Oral Sci 2011;10:241-5.
Araujo MW, Andreana S. Risk and prevention of transmission of infectious diseases in dentistry. Quintessence Int 2002;33:376-82.
Singh A, Purohit BM, Bhambal A, Saxena S, Singh A, Gupta A. Knowledge, attitudes, and practice regarding infection control measures among dental students in Central India. J Dent Educ 2011;75:421-7.
Crossley ML. A qualitative exploration of dental practitioners' knowledge, attitudes and practices towards HIV+and patients with other 'high risk' groups. Br Dent J 2004;197:21-6.
Tibdewal H, Barad P, Kumar S. Comparing dental and medical student's knowledge and attitudes toward hepatitis B, C and HIV infected patients in India – A cross-sectional study. J Int Oral Health 2009;1:20-32.
[Table 1], [Table 2]