Hepatitis B and C related knowledge, attitudes and practices of health care workers in Azad Kashmir, Pakistan –A potentially disastrous area

Background: Azad Kashmir, Pakistan is potentially dangerous area for earthquake disasters. Knowledge, attitude and practices (KAP) of health care workers (HCW’s) in this region is essential to prevent spread of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) in case of disaster. 
Methodology: This descriptive observational prospective study was carried out to assess the HCW’s KAP regarding HBV and HCV in major hospitals of Muzaffarabad, Azad Kashmir, Pakistan. A validated study questionnaire was distributed among 320 HCW’s of Combined Military Hospital (CMH) and Abbas Institute of Medical Sciences (AIMS), Muzaffarabad, to assess KAP of HCW’s regarding HBV and HCV. All HCW’s of CMH and AIMS, Muzaffarabad were included in the study. While, HCW’s of these hospitals with HBV and HCV infection were excluded from the study. Analysis was done in Microsoft Excel and Graphs were generated for KAP of health care workers. 
Results: In knowledge component all health care workers know about parenteral transmission of Hepatitis B & C (100%) but their knowledge regarding non-parenteral transmission is incorrect (65.62% and 31.2%). Knowledge about prevention status after Hepatitis B vaccine is also incomplete (40.62%). Hepatitis B & C related attitude in health care workers is acceptable. Overall practice regarding Hepatitis B & C spread is acceptable but half of the health care workers have knowledge regarding use of immunoglobulins after Hepatitis B & C infection and regarding continuity of work after accidental exposure to Hepatitis B or C (43.75% and 28.12%). 
Conclusion: Our study found gaps in KAP of HCW’s. The shortcomings found in KAP of HCW’s needs to be addressed through regular educational programs in order to prevent the spread of HBV and HCV in the studied.


Introduction
Hepatitis B and C viruses are documented globally as a significant hazard for health care worker 1  In the event of a disaster, mass causalities and injured people were handled by local and international organizations with limited resources hence the level of their KAP, regarding different diseases is important to prevent the further spread of diseases like HBV and HCV infections 4 . Mass causalities in a disaster can serve as the source for the spread of HBV and HCV viruses 4 . Many studies were done to check the prevalence of HCV and HBV among different regions of Pakistan 4 . A survey conducted by Pakistan Medical and Research Council from July 2007 to May 2008 showed the prevalence of HBV and HCV was 2.5% to 5%, the HBV was found more common among the males as compared to females 4 . Another small study showed a significant variation of prevalence among different areas of the country 5 .
Province wise HBV prevalence is highest in Baluchistan (4.3 %) while Sind, Punjab and Khyber Pakhtoonkhwa showed a prevalence of 2.5%, 2.4% and 1.3% respectively 4 . HCV was highest in Punjab (6.7%) followed by Sindh (5.0%), Balochistan (1.5%) and Khyber Pakhtoonkhwa (1.1 %) 6 . Naz et al., conducted a study in Muzaffarabad which reported that subjects were mostly male and very few were females 7 . Similarly, a study carried out by Sarwar et al., in collaboration with district headquarter hospital, Kotli, Azad Kashmir reported that most of the subjects were found positive for both HBV and HCV 8 .
About 10% of the world's population is affected by HBV, making it a significant public health care problem 9 . As per WHO (world health organization) report of 2009, each year about 2 billion people are affected by HBV, more than 350 million suffer from chronic infection and more than a million die due to cirrhosis or HBV related hepatic cancer [9][10][11] . Almost 150 to 200 million people are infected worldwide with HCV 12 . Due to occupational exposure to HBV and HCV infected materials, especially infected blood, body fluids exposure or infected hollow needle stick injury, HCW's are at high risk of acquiring HBV or HCV infection 9,11&13 . HCV spread is related to blood transfusion, intravenous drug use, blood-to-blood contact and use of unsterilized medical equipment 14 . As per universal precautions, body fluids and blood of all patients are considered infectious for HBV and HCV 3 . Hepatitis B vaccine is effective in preventing HBV infection in HCW's and other individuals 11 . Pre-exposure HBV vaccination is the most effective way of preventing HBV 9 . Health care workers should maintain the immunity level of >10mIU/mL for HBV and their respective hiring agencies should provide the opportunity to have hepatitis B vaccination.

Methodology
This descriptive observational prospective study was carried out from 1st November to 31st December 2016. The study was carried out at Combined Military Hospital (CMH) and Abbas Institute of Medical Sciences (AIMS), Muzaffarabad, Azad Kashmir, Pakistan. All HCW's of CMH and AIMS, Muzaffarabad were included in the study. While HCW's of these hospitals with HBV and HCV infection were excluded from the study. Total 320 HCW's of CMH and AIMS Muzaffarabad were enrolled voluntarily in the study. A validated study questionnaire to assess KAP of HCW's regarding HBV and HCV was distributed among the study participants. Data analysis was done using Microsoft Excel and Graphs were generated for knowledge, attitudes and practices of health care workers.

Results
Out of 320 HCW's 230 (71.87%) were nurses, 47 (14.68%) were doctors, 30 (9.37%) were technicians and 13 (4.06%) were others including pharmacists.  The knowledge of HCW's is appropriate for most of the questions but they lack knowledge regarding nonparenteral transmission of HBV and HCV. About 65.62% of HCW's belief that HBV and HCV can spread through the use of the contaminated comb. A significant proportion of HCW's responded that HBV and HCV spread through contaminated water. Among all 40.62%, HCW's believe that persons vaccinated for HBV are completely safe from getting HBV infection.

Discussion
Several studies have shown that HCW's are at higher risk of having HBV infection as compared to the general population 15 16 which is very near to the response to the same question i.e. 100% in our study (Figure 1). Our study showed that 34.37% of HCW's believe that HBV and HBC spread through contaminated water ( Figure  1) which is almost similar (37.4%) to the results of a study done by Noman ul haq et al., regarding the same question for HBV transmission 17 .
A study similar to our study was conducted by Gunson et al in 2003, reported that infection control and prevention of HCW's depends upon the long term maintenance of immunity of HCW's 18 . It protects HCW's and prevents the spread of disease from affected HCW to the patient 18 . In Karachi, most of the tertiary care hospitals did not provide training to their HCW's about knowledge of safe injection practice, universal precautions (UP) and body fluid isolation (BSI). However, we cannot generalize our results in comparison to this study as there exists a vast difference in the sample size.
Our study showed, that almost all of the HCW's were immunized for Hepatitis B (Figure 3). Nasir et al., noted that most doctors, 33% paramedics, 37% of nurses were not aware of the fact that they are among the high-risk group 19 . Participant of our study 45% were also considered unaware ( Figure 3). In Karachi 86% of the HCW's were completely immunized, out of those not immunized, 9% found vaccine too expensive and 15% were expected for free vaccine provided by the respective healthcare employer. Other Studies were established at Lahore and Athens reported immunized HCW's 49% and 57% respectively 20&21 . These studies are comparable with the present study in the sense of knowledge of vaccination. But the percentile of knowledge about vaccination in our study is different (Figure 3). Our study showed that most of the HCW's (93.75%) are vaccinated for Hepatitis B. The present study is much more variable as compared to these studies because of hepatitis C knowledge and practices of HCW's as well as knowledge and practices of hepatitis B. It is to be noted that75% of HCW's did not follow safe injection practices ( Figure 3). Safe practices were not followed in body substance isolation procedures (68%) (Figure 1). About 90% HCW's not followed the appropriate aseptic technique and 81% were using improper sterilization techniques ( Figure  2).

Conflicts of Interest
None.
International Journal of Endorsing Health Science Research ©Int. j. endorsing health sci. res.