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Hepatitis B Vaccine Amid Health Care Service ProvidersArticle

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Hepatitis-B virus (HBV) causes a most severe, deadly liver disease that goes by the same name. Its vaccine has, since 1982, proven remarkably successful in terms of effectiveness and safety, thereby ensuring its administration to every healthcare worker (HCW), for safeguarding them against occupational exposure.

To deduce HBV-immunization coverage extent, views and knowledge regarding it, and obstacles to proper immunization of primary HCWs.

This descriptive, cross-sectional research employed a self-administered questionnaire, which was handed out to PHCWs in four primary healthcare divisions affiliated to Al-Madinah Al-Munawwarah's Directorate General of Health Affairs.

The study randomly chose 645 PHCWs; 542 completed questionnaires were handed in, thus making the total response rate 84%. Outcomes indicated that 73.8% PHCWs were fully vaccinated, 15.9% partially vaccinated, and 10.3% never received vaccination.

Conclusions: Primary preventive strategies, like universal precaution and immunization, for safeguarding PHCWs from HBV, must be implemented.

1.1 Background

The Hepatitis B virus (HBV) causes an acute, deadly liver disease, and constitutes a crucial global health issue. HBV initiates chronic liver problems, resulting in death from liver cancer and cirrhosis.1-2-3Around 2 billion individuals worldwide are estimated to be HBV-infected; over 350 million develop chronic liver diseases.1the backbone of HBV-protection comes from its vaccine-- the most effective HBV-curbing intervention. The World Health Organization (WHO), in 1991, recommended it to all nations; by 2009, 177 nations reported all babies receiving the vaccine. Worldwide estimated HBV-vaccine coverage was around 69% in 2008.4-5Nearly 0.5-1.2 million individuals succumb to HBV-complications per annum.6-7

HBV vaccine has, since 1982, proven remarkably successful in terms of effectiveness and safety; over a billion HBV-vaccines have globally been administered. Immunization has decreased chronic infection in several nations, wherein 8-15% kids would contract chronic HBV-triggered infection. This first-ever vaccine for a major form of cancer offers lifelong (minimum 20-years') protection.8 Drop in HBV-infection occurrence and associated morbidity/mortality rates owing to the vaccine led the Centers for Disease Control and Prevention (CDC) to mandate HBV-inoculation for all HCWs in 1997.9still, there is poor compliance in numerous healthcare settings, particularly in developing nations; Saudi Arabia's HCW-immunization status is yet unclear. The country presents no recent HCW HBV-vaccine coverage study; only one prior research exists, portraying 39% coverage.10

HCWs are directly exposed to infected patients (blood pathogens / body fluids) in healthcare facilities and labs.11 HB-infection constitutes an occupational hazard, chiefly transmitted via contaminated body fluids/blood. Global HBV burden projected 66000 HB-cases and 261 annual HCW deaths due solely to infected sharp-objects. Barely 40-60% developing nations' HCWs become HBV-infected because of percutaneous sharp-object-inflicted occupational exposure.12Since 1981, HB has become preventable because of its efficient, immunogenic vaccine.13

The WHO's mean estimates of HBV-immunization among developing nations' HCWs was 19-39% as opposed to developed nations' 67-79% estimate.12Chiefly, the program has been successful, ensuring HCWs' immunity against all preventable illnesses. High HCW HBV-immunity rates helps decrease disease transmission. It is easier to prevent and reduce HBV-connected occupational hazards via immunization programs for HCWs than to manage and control disease outbreak.14Saudi Arabian vaccination recommendations are identical to CDC recommendations,15 i.e., HB-vaccine administration in 3 doses, with second and third doses administered 1 & 6 months after first dose to at-risk HCWs. Most Saudi Arabian researches on HBV-vaccination involve dentists, other specific healthcare segment' specialists, 16 or special, Hajj-season HCWs.17 There is no research as yet regarding Saudi Arabian PHCWs' hepatitis B vaccination coverage.

1.2. Study Significance

Study outcomes will aid national occupational health and infection control policies for Saudi HCWs. HCW-immunization (thereby disease-prevention) is much more economical than treatment/management after contracting HBV-infection. Outcomes will ascertain infection control and assess immunization program efficacy.


1.3.1 HB Epidemiology

Causative agent

HBV causes hepatitis (liver inflammation) which may cause other infections like asymptomatic infection, and chronic/acute infection (resulting in hepatocellular carcinoma and liver cirrhosis.)18 Transmission

HBV-transmission occurs by contact with infected body fluids (blood, saliva, semen.)19 Unprotected sex20, contaminated syringes/needles21, percutaneous and parenteral exposure (acupuncture, tattooing, household contact, transfusions and dialysis25) and infant-exposure via mother23-24 are major transmission modes. HCWs have greatest HBV risk.22


HBV-impregnated needles are the leading HBV-transmission mode among HCWs. Average inoculated-blood volume via needle-pricks decides HBV-transmission risk. Research of HCWs exposed to HBV in this manner showed 6-14% contracting the disease and 27-45% developing serologic HBV-infection evidence.26 HBV Prevalence

HBV distribution can be segregated in 3 levels (low-intermediate-high) depending on disease endemicity. Developing areas, like China, Africa's sub-Sahara, Amazon Basin and South-East Asia are highly endemic (>8% HBV-carriers).4 Japan, Middle East, Mediterranean countries and East European nations are moderately endemic (2-8% carriers); other regions in these zones, South-Europe, and some South American areas have 10-60% carriers.3US, Australia, other South American regions, and Western and Northern Europe have low endemicity (0.5-2% carriers, with 5-7% infected individuals).30

Saudi Arabia has moderate-to-high HBV-rate (>2% carriers).31

A Saudi Arabian research on 8-year hepatitis A/B/C-sero-positivity occurrence trends in the population utilized King Abdul-Aziz Medical City's surveillance system. Study outcomes depicted average annual HBV-seropositivity occurrence to be 104.6 per 100,000 individuals.31 HBV is estimated to affect over 2 billion individuals globally, with around 360 million suffer chronic infection, and acute illness and mortality risks (primarily from HCC and liver cirrhosis). Mathematical modeling projected annual global HBV-associated deaths in 2000 at around 600,000.27 Prevention and control

Key interventions for reduction/prevention of HBV's global prevalence concentrate on highly-endemic, developing nations; the leading intervention has three components: behavior change for control/reduction of infection spread, active immunization, and passive immunoprophylaxis. HBV-vaccine's first generation, obtained from inactive plasma was introduced in 1982; in 1986, its second generation became available to public.32-33the vaccine forms the core of HB-prevention (95% effectiveness).34the WHO, in 1991, recommended it to all babies, particularly in countries with ?8% carrier prevalence.35 It is administered in 3 doses across a 6-month duration (0-1-6).

HCWs in contact with patients' body fluids/blood must be HBV-vaccinated in three doses. Anti-HB tests must be conducted for recording immunity after 1-2 months post-immunization:

• Positive: 10mIU/mL (milli-international units per milliliter) anti-HBs indicate that HCW is immune and requires no additional immunization/serologic testing.

• Negative: <10mIU/mL anti-HBs indicates HBV-vulnerability, necessitating revaccination (another 3 doses), followed by retesting anti-HBs. If retest also indicates negative outcomes, individual is non-responder.

Non-responders are HBV-vulnerable and must be extra-cautious and take HBIG prophylaxis after probable/known HBV-exposure.1 Non-responders may (possibly) already be HB-carriers, and should be tested. HBV-affected HCWs must be guided and evaluated medically.

Immunized HCWs (untested 1-2 months post-original-immunization) don't require regular anti-HBs testing, unless exposed to body fluids/blood. HCWs with negative outcomes are at risk.


A 2002-03 U.S. cross-sectional research for ascertaining HCWs' HBV-vaccination coverage and policies surveyed, systematically, 425 out of 6,116 hospitals belonging to the American Hospital Associations. Of 75% surveyed HCWs, 81% nurses/physicians, 71.1% phlebotomists and 70.9% nurse aides/other patient-care personnel received ?3 HBV-vaccine doses.79.5% white HCWs and 67.6% black HCWs received immunization. Low-risk HCWs who only required inoculation were considerably less-covered (76.6%) than at-risk HCWs (exposed to potentially-contaminated substances).36

Cross-sectional research on Greece's military hospitals for estimating HCWs' HB-immunization and establishing coverage-linked factors gave 245 nurses from seven military hospitals self-administrated questionnaires. 75.5% respondents self-reported vaccine coverage; RNs' coverage was more than nurse aides'. Positive beliefs/attitudes were associated with immunization acceptance/compliance; HCWs were aware of HBV being a crucial occupational hazard. Results proved the need for increased coverage/compliance, through developing targeted immunization programs for non-vaccinated, at-risk HCWs.37

Another similar 2006-08 Greek study interviewed 338 Korinthos General Hospital specialists (59.8% nurses, 19.5% physicians, 7.4% technical services personnel, 6.5% cleaning personnel, and 3.8% administrative staff) before testing, followed by providing additional written data and administering a questionnaire. It addressed vaccination history for several vaccines. 58.6% respondents received HB-vaccination: 47.6% tested positive for anti-HB, while 1.2% showed HB-infection. 27.5% participants were tested for Tuberculosis, out of which 28% showed positive results. 15.4% received Tetanus vaccination, 6.5% tested positive for Anti-HBc, and 0.3% were Anti-HCV-positive.38

A 2010 Brazilian cross-sectional, analytic research verified incidence and factors linked to HB-vaccination among PHCWs (physicians, dentists, nurses, community healthcare agents, oral health and nursing assistant/technicians). A form was used to procure socio-demographic, behavioral, occupational, and general health data from 797 PHCWs. 762 PHCWs responded (95.6%); all but one of these (95.5%) answered the vaccination question, 52.5% reported completion of three doses and 47.5% received incomplete immunization. Older hired workers reported low immunization prevalence, consumed alcohol, and failed to update their occupational health knowledge; more educated staff and members exposed to sharp instruments revealed higher prevalence.39

A 2010-11 KwaZulu-Natal hospital descriptive, observational research determined HB-immunity of sharp-object-injured HCWs, and assessed their attitude/knowledge regarding HBV-immunization. Participants were handed structured questionnaires; results were: 67 of 78 doctors (respondents) suffered sharp-object injuries, out of which 39% weren't HB- immunized, while 19% were administered HB-immunoglobulin. 65% respondents suffered ?1 injury; 56% didn't know their HB-immunity status; 31% were administered a booster dose in the last 5 years; 90% conceded that PEP (post-exposure prophylaxis) for HBV was equally vital as prophylaxis for HIV. 84% respondents agreed that anti-HB testing was crucial after an injury. Respondents' HBV-knowledge was poor- 67% underestimated HB-transmission risk; only 33% knew of it. 61% doctors (22%… [END OF PREVIEW]

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