Knowledge, Attitude and Practice of Hepatitis-B Vaccination among Clinical Medical Students at a Medical College in Nepal

Background: Hepatitis B vaccine is the single most effective and safest strategy for the prevention of the disease among health care workers (HCW), trainees and medical students. There is scanty information on knowledge, attitude and practice (KAP) regarding Hepatitis B vaccination among medical students who are likely to get exposed in the future as they start practicing. This study was undertaken to understand the knowledge, attitude and practice of hepatitis B vaccination among clinical medical students of Manipal College of Medical sciences at Pokhara, Nepal. Methods: Two hundred and four medical students were enrolled for a descriptive cross-sectional study at Manipal College of Medical sciences at Pokhara, Nepal after obtaining ethical clearance from Institutional Review Committee. Answers to pre-tested questionnaire were collected. Knowledge, attitude and practice regarding Hepatitis B vaccination were studied. Results: All participants demonstrated good knowledge and positive attitude towards Hepatitis B infection and vaccination. However majority had poor practice towards it. Only 47.1% were completely vaccinated. The most common reason for non vaccination was that many thought they will vaccinate in internship or when they start practicing. Conclusions: Despite good knowledge and positive attitude towards Hepatitis B infection and vaccination, low rates of vaccination and poor practice was observed among medical students indicating the necessity of encouragement for vaccination and proper practices among them. All medical students should be immunized against Hepatitis B during their medical school. Regular Hepatitis B vaccination, educational and awareness programs must be conducted in coordination and with active participation of the medical students.


INTRODUCTION
Hepatitis-B virus (HBV) infection is a worldwide healthcare problem. 1 About 10% of the patients develop chronic hepatitis and about 15%-25% develop cirrhosis after infection with HBV. 2,3 National study on HBV has shown upto 2.7% prevalence among high risk group with injecting drugs in Western Nepal. 4 Hepatitis B is the major infectious occupational health hazard for hospital staffs because of their repeated exposure. 5 All the hospital staffs including trainees and medical students are at occupational risk of HBV infection. The risk of accidental exposure among the trainees could be even higher due to their non experience, insufficient training and lack of preventive knowledge. 5 Hepatitis B virus infection is one of the most preventable causes of chronic liver disease. 5 Hepatitis B vaccine is the single most effective and safe strategy for the prevention of the disease. 6 World Health Organization (WHO) has recommended vaccination to people at occupational risks of Hepatitis B virus infection. 7 Despite of high occupational risk among health professionals, the WHO estimate showed that HBV vaccination coverage among Health care workers (HCW) is low worldwide. 7 Studies regarding the prevailing knowledge, attitude and practice of Hepatitis B vaccination among medical students within the country are scanty. This study was therefore carried out to determine the knowledge, attitude and practice of Hepatitis B vaccination among clinical medical students at Manipal College of Medical Sciences at Pokhara, Nepal.

MATERIALS AND METHODS
This descriptive, cross-sectional study was conducted at Manipal College of Medical Sciences and Teaching Hospital at Pokhara, Gandaki Province from 1 st June to 30th June 2020, over a period of 1 month. The study was conducted after obtaining ethical clearance from Institutional Research Committee (MEMG/IRC/334/GA) and informed consent from study participants.
The college runs an undergraduate MBBS programme and recruits a batch of 100 students each year. Previous batches, including this study batch contained 135 medical students. All clinical medical students of 3rd and 4th (Final) year MBBS were enrolled in the study. Subjects who were absent during the study period and those who did not return the questionnaire were excluded from the study. This included pre-tested questionnaire that were categorized into 3 sections: section 1knowledge, section 2-attitude, section 3-practice of Hepatitis B vaccination. Each correct response was scored as one mark and incorrect or non response was scored zero. Level of knowledge was graded as good or adequate for participants who scored ≥50% and poor when <50%. Similarly, for attitudes and practices, participants achieving ≥50% were classified as having positive attitudes and safe practices, respectively and <50% as having negative attitude and poor practices.
The data analysis was done using SPSS Version 16. All categorical data were expressed in percent and absolute number. All numerical continuous data were expressed in mean ±SD. Chi squared test / fisher exact test were used to test for significant difference of proportions and mean. All tests were analyzed with a 95% confidence interval and a p value of <0.05 was considered significant.

Attitude towards Hepatitis B vaccination
Majority comprising of 198 (97.1%) respondents had positive attitude towards Hepatitis B infection and vaccination. The mean attitude score of the study subjects was 80.59 ± 12.83 (Table 2). Majority comprising of 186 (90.2%) respondents informed that they might be at risk once they start practicing after completing medical school and all medical students felt that they need to be protected against Hepatitis B. Majority comprising of 165 (80.9%) respondents considered it was a safe vaccine and 147 (72.1%) trusted its efficacy. All students believed that vaccination must be compulsory to all medical students before they complete their medical school, 188(92.1%) felt that more students would be vaccinated if provided for free and 183(89.7%) believed that regular vaccination campaigns must be conducted in the hospitals . Majority comprising of 194 (95.1%) respondents were willing to receive or complete their Hepatitis B vaccination if not vaccinated or incompletely vaccinated and 161 (78.9%) would recommend vaccination to their friends at work (Table 3).

Factors associated with non vaccination against Hepatitis B
A total of 84(41.2%) clinical medical students had never received even a single dose of hepatitis B vaccine. The most common reason for non vaccination described by 40 (47.6%) medical students was that they thought they will vaccinate in internship or when they start practicing. The other reasons mentioned were negligence by   24(28.6%) medical students followed by not really felt or realized by 8 (9.5 %), afraid of injection by 6(7.1%) and rest 6 (7.1%) medical students had no reasons.
All medical students of both the clinical years demonstrated good knowledge and good attitude overall. There was statistically no significant association between sex and clinical medical year against level of knowledge and attitude for hepatitis B vaccination (p>0.05) ( Table 5).
Despite, good knowledge and good attitude, all medical students of both clinical years showed a poor practice. There was statistically no significant association between sex and clinical medical years with practice towards Hepatitis B vaccination (p>0.05). Among the respondents in the current study, 83.3% knew that hepatitis B is not spread by handshaking. It was reported by 93% medical students in the study by Jacob et al. 9 In the current study, 78.4 % medical students knew about effective hepatitis B vaccine .Whereas even greater frequencies of knowledge by 86.5%, 89.6% and 94.6% medical students were documented in the studies by Alhowaish et al. 11 in Saudi Arabia, Jacob et al. 9 and Vasantha et al. 8 in India respectively.

DISCUSSION
Majority (97.1%) of the respondents had positive attitude towards Hepatitis B vaccination. In India, studies by Vasantha et al. 8 , Chhabra et al. 12 and Jacob et al. 9 reported positive attitude by 77.56%, 80.6% and 84.3% respectively. Whereas, 67.6% of the students demonstrated a poor attitude in the study by Fortes et al. 10 in Senegal.
In the current study, 80.9% of the medical students believed that it was a safe vaccine and 72.1% trusted its efficacy. Even better were the findings in the study by Alhowaish et al. 11 in Saudi Arabia where 86.5% believed that HBV vaccine was safe and 90% believed that following proper infection and control guidelines, it would protect them from  15 in Pakistan, Vasantha et al. 8 in India and Fortes et al. 10 in Senegal suggested that 80.6%, 79.5% and 61.3% of the students were fully vaccinated respectively. At the other hand, very low, i.e. only 8% and 2% of the medical students were fully vaccinated in the studies by Rathi et al. 16 and Abdela et al. 17 respectively.
Studies have also demonstrated tendency of incomplete vaccination among medical students.
In the current study, 11.7% students were partially vaccinated against Hepatitis B Virus infection whereas 20.5% and 18.7% were partially vaccinated in the Indian studies by Vasantha et al. 8 and Rathi et al. 16 respectively. In our current study, 41.2% were never vaccinated against Hepatitis B whereas, even a larger mass of 73.3% was not vaccinated in the Indian study by Rathi et al. 16 All these studies suggest that majority of medical students despite having adequate knowledge and good practice regarding hepatitis infection and importance of vaccination , however many are not vaccinated. Those who get vaccinated, some of them fail to complete the recommended schedule.
The most common reason for non vaccination in the current study described by 47.6% was that they thought they will vaccinate in internship. The other reasons were negligence in 28.6 % followed by felt no necessity or not realized in 9.5 %, afraid of injection in 7.1% and rest 7.1% had no reasons. The common reasons were lack of information by 39.3%, not felt necessity in 35.6% , negligence in 22% and fear of injection in 2.9 % in the Yemenian study by Almulam et al., 18 reasoning almost similar to ours.
The practice of testing for antibodies for confirming immunization post vaccination was even very low among the medical students. Among the respondents in the current study, only 9.3% had checked their immune status post vaccination. It was only 7% according to the study by Chhabra et al. 12 Among the respondents, 63.7 % had participated in some form of educational program or campaign against Hepatitis B .whereas , only 17.8% and 8.8% had participated in such programs according to Jacob et al. 9 and Almulam et al. 18 respectively .
This study had its own limitations. The study reflects the knowledge, attitude and practice of a group of MBBS clinical medical students of a medical school which may not be uniform to all medical students within the country. Larger sample size with multi centers study is recommended.

CONCLUSION
Despite the good knowledge and positive attitude towards Hepatitis B infection and vaccination, many medical students have poor practice towards it indicating the necessity of encouragement for vaccination and proper practices among them.
All medical students should be protected and immunized against Hepatitis B followed by confirmation of immunization with post vaccination antibodies testing before their occupational exposure in hospitals and their practices. Regular Hepatitis B vaccination, educational and awareness programs with active participation of the medical students are highly recommended.