Knowledge of Hepatitis B Management and its Prevention Among the Staff Nurse working

Introduction:

HBV is a member of hepadna virus family. It is a DNA virus surrounded by an envelope which contains HBsAg surface antigen. HBsAg is important for laboratory diagnosis and immunization. In addition to HBsAg, there are two other important antigens: Core antigen (HBcAg) and e antigen (HBeAg). HBsAg is an important indicator of transmissibility. All persons who are HBsAg positive are potentially infectious. HBV is 50-100 times more infectious than HIV. Infectivity of chronically infected individuals varies from high HBeAg positive to modest anti- HBe antibody positive ^1.

 The hepatitis B virus (HBV) is a DNA hepadna virus. Important components of the viral particle include hepatitis B surface antigen (HBsAg), hepatitis B core antigen (HBcAg), and hepatitis B e antigen (HBeAg) ^1.

Infection with HBV may result in acute or chronic disease, both of which can be asymptomatic. If symptoms are present, onset of acute disease is usually insidious, with loss of appetite, vague abdominal discomfort, nausea, vomiting, and sometimes arthralgias and rash, often progressing to jaundice. Fever may be absent or low-grade. Liver enzyme levels are markedly elevated. Severity of the disease ranges from unapparent cases (detectable only by liver function tests) to fulminant, fatal disease. The case-fatality rate in hospitalized patients is about 1%. Disease tends to be worse and mortality higher in those over 40 years old. Asymptomatic infections are common in children <10 years of age. Approximately 30–50% of older children, adolescents, and adults have asymptomatic infections ^6.

The risk of chronic infection decreases with age at infection. More than 90% of infants infected at birth (perinatally) will develop chronic HBV infection, compared to between 25–50% of children infected between 1–5 years of age and 6–10% of those acquiring infection as older children or adults. Chronically infected persons are at increased risk for developing chronic liver disease (e.g., cirrhosis or chronic hepatitis) or liver cancer (primary hepatocellular carcinoma) later in life ^{4 .} Up to 25% of those infected during early childhood will ultimately die at an early age from the complications of cirrhosis and liver cancer ^.Patients who develop acute HBV infection while immunosuppressed and patients with an underlying chronic illness have an increased risk of developing chronic infection ^7-8.

Resolved hepatitis B is defined as the clearance of HBsAg and normalization of serum transaminase concentrations; development of antibody to HBsAg (anti-HBs), which provides protection from HBV infection, may also be noted. Chronically infected adults clear HBsAg and develop anti-HBs at the rate of 1–2% annually; during childhood, the annual clearance rate is <1%. Reactivation of inactive chronic infection is possible with immunosuppression. Vectors and Reservoirs is Humans are the only natural host for HBV  ^15.

HBV is transmitted through blood or body fluids, including wound exudates, semen, vaginal secretions, and saliva. Blood and serum contain the highest concentrations of the virus; saliva contains the lowest. Common modes of transmission include percutaneous and permucosal exposure to infectious body fluids, sharing or using nonsterilized needles or syringes, sexual contact with an infected person, and perinatal exposure from an infected mother ^{14, 20.}

 Some examples of parenteral exposures are: needle sticks, sharing or reusing non-sterile needles or syringes, transfusion of blood and blood products (rare in the U.S. due to current blood donor screening and testing protocols), hemodialysis, and tattooing 16. The most common permucosal exposures are through perinatal transmission from an infected mother to her infant at birth (vertical transmission) and sexual (heterosexual and homosexual) activity (horizontal transmission). Permucosal exposures have occurred in laboratories and health care settings, contributing to horizontal transmission in facilities and communities. However, with universal immunization of health care workers who are at risk, this has become rare in the U.S ^{2-5 ,11-12.}

Person-to-person spread of HBV can occur in settings involving interpersonal contact over extended periods, such as when a chronically infected person resides in a household. In household settings, nonsexual transmission occurs primarily from child to child, and young children are at highest risk for infection ^15. The precise mechanisms of transmission from child to child are unknown; however, frequent interpersonal contact of non-intact skin or mucous membranes with blood-containing secretions or saliva are the most likely means of transmission. Sharing of personal items such as washcloths, towels, razors, or tooth brushes, are behaviors that could facilitate transmission. Fecal-oral transmission does not appear to occur. Approximately one-third of infected persons do not have a readily identifiable risk factor ^10-12,19.

The incubation period of HBV infection averages 60–90 days, with a range of 45–160 days. HBV can remain infectious at ambient temperatures in the environment for one week or longer.

A person is considered infectious as long as HBsAg is detectable in the blood. Persons who have chronic HBV (known as carriers) remain infectious indefinitely. Persons with acute and chronic HBV with circulating HBeAg are more infectious than those who are HBeAg negative. Measurable levels of HBeAg are associated with higher levels of HBV replication ^10-11.

Worldwide, HBV is a major cause of chronic liver disease and liver cancer. The frequency of HBV infection and patterns of transmission vary greatly throughout the world. In most areas of the U.S., Canada, Western Europe, Australia, and southern South America, the infection rate is low, and infection occurs primarily in adolescents and adults; 5–8% of the total population is infected, and 0.2–0.9% has a chronic infection. In contrast, HBV infection is highly endemic in China, Southeast Asia, the Pacific Islands, Eastern Europe ^11-12,17, the Central Asian republics, and in most of the Middle East, Africa, and the Amazon Basin. In these areas, most infections occur in infants or children under the age of five years; 70–90% of the adult population has been infected, and 8–15% have a chronic infection. In the rest of the world, HBV infection is of intermediate endemicity and occurs in all age groups, with chronic HBV carriage occurring in 2–7% of the population ^13.

In the U.S., sexual contact is the most common risk factor for HBV infection, and injection drug use and household contact with a chronic carrier are the second and third most common risk factors. Within the U.S., there are pockets of high endemicity, including first-generation immigrants from areas where HBV is endemic, Alaskan Natives, and some inner city populations. The highest risk of early childhood infection is among children born to mothers from HBV endemic countries. Other young children at risk of infection include: a) household contacts of people with chronic HBV infection; b) residents of institutions for the developmentally disabled; c) patients undergoing hemodialysis; and d) patients with clotting disorders and others repeatedly receiving blood products. Although fewer than 10% of new HBV infections occur in children, approximately one third of the estimated 1.25 million Americans with chronic HBV acquired the infection as infants or young children ^2-3,17.

Acute HBV infection occurs most commonly among adolescents and adults. groups at highest risk include users of injection drugs, people with multiple heterosexual partners, and young men who have sex with men. Others at increased risk include staff of institutions and non-residential childcare programs for the developmentally disabled, patients undergoing hemodialysis, and sexual or household contacts of people with an acute or chronic infection. The prevalence of infection among adolescents and adults is 3–4 times greater for blacks than for whites. HBV infection in adolescents and adults is associated with other sexually transmitted diseases, including syphilis and human immunodeficiency virus (HIV) ^15,18.

Acceptance of vaccination by healthcare workers (HCWs) is an essential issue for hospitals, since staff and medical and paramedical students are at risk of exposure to, and transmission of, vaccine-prevent­able diseases ^6-7. Although the currently-available hepatitis B vaccines are extremely safe ^5-8 . unfortu­nately, rates of vaccination among high-risk groups, i.e. medical, nursing staff, and other healthcare workers, are low. A study in Lahore, Pakistan, found that only 49.0% of healthcare workers and 42.2% of medical students were vaccinated ⁹. Nurses of­ten have to deal with spilt blood, needlestick and sharps injuries, which can transmit blood-borne in­fections between patients and healthcare staff, and infection with the HBV is a common result ^7,10-14. Although nurses are clearly a high-risk sub­ group for such events, nursing students may be at a similar or even at a greater risk due to their limited clinical experience ^12. Despite this, the vaccina­tion coverage among nursing students in Pakistan has not been elucidated. Bolan Medical Complex, Quetta, is a tertiary hospital in Baluchistan prov­ince. Nursing students receive HBV vaccinations at the beginning of their clinical rotations. Due to limited budget, not all students can get vaccination on time. During the study period, the hospital had no written policy that all healthcare workers and medical and nursing students are offered free HBV vaccination. Accordingly, this study aimed at ex­amining the prevalence of and factors relating to acceptance of HBV vaccination by nursing students in this tertiary hospital ^5,15-17.

 Rationale:

Hepatitis B virus is endemic worldwide with the highest rates found in developing countries. It has been estimated that more than 200 million people have been infected with the HBV. There are an estimated 300 million carriers.

Hepatitis B virus has been estimated by the World Health Organization to infect over two billion people worldwide. Approximately 500 million are chronic carriers. Transmission of HBV is primarily through blood and or sexual contact, though other methods of transmission have been suggested. Among the diseases, which have public health programs throughout the world Hepatitis B infection is one of them. Hepatitis B causes suffering to all categories of people. The knowledge about Hepatitis B infection is among the common people. Consciousness can only be increased when people are fully aware of Hepatitis B infection.

Hepatitis B is the most fatal among the others Hepatitis viruses but it is preventable disease. An individual can prevent it and make him or her safe from infection if he or she is immunized or abide by some precautions, which are suggested by public health specialist.

In Bangladesh Hepatitis B infection is also a major Public health problem. On an around 8%  apparently healthy persons are  infected with Hepatitis B virus 18.2%  blood donors, 60.1% patients with history of blood transfusion, 65.5% physicians with acute Hepatitis of large hospitals in Bangladesh where found Hepatitis B infected.

Literature   Review

Hepatitis B is the most common serious liver infection in the world. Worldwide, about 350 million people are chronic carriers of HBV, of whom, more than 250,000 die from liver-related disease each year. Even in the United States, hepatitis B is largely a disease of young adults aged 20-50 years. About 1.25 million people are chronic carriers, and the disease causes about 5000 deaths each year. But the good news is that infection with HBV is almost always preventable. Anyone can protect himself and loved ones from hepatitis B if it is identified properly, and preventive measures can be taken within quickest possible time ^1.

Hepatitis B is caused by infection with the hepatitis B virus (HBV). This infection has 2 phases: acute and chronic.  Acute (new, short-term) hepatitis B occurs shortly after exposure to the virus. A small number of people develop a very severe, life-threatening form of acute hepatitis called fulminant hepatitis. Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts longer than 6 months. Once the infection becomes chronic, it may never go away completely. It is also a striking information that, About 90-95% of people who are infected are able to fight off the virus so their infection never becomes chronic. Only about 5-10 percent of adults infected with HBV go on to develop chronic infection. HBV infection is one of the most important causes of infectious hepatitis ^{2-3 .}

People who are infected, needs to take care on some of the following issues which are given as follows:

• In case of injecting drugs, not to share needles or other equipment.
• Don’t share anything that might have blood on it, such as a razor or tooth brush.
• Think about the health risks for any health risks and operation which can infect if it fails to ensure sterilize needles and equipment, use disposable gloves, or wash hands properly.
• Follow standard precautions and handle needles and sharps safely.
• ^·           In case of pregnant or children, it is to be identified by health care provider to recheck if there is  any of the risk factors for HBV infection  ^12.
• ^·          If sexually active, safe sex should be practiced. Correct use of latex condoms can help prevent transmission of HBV, but even when used correctly, condoms are not 100% effective at preventing transmission ^14.

People with chronic HBV infection are called chronic carriers. About two-thirds of these people do not themselves get sick or die of the virus, but they can transmit it to other people. The remaining one third develops chronic hepatitis B, a disease of the liver that can be very serious.

The liver is an essential organ that the body needs to stay alive. Its most important functions are filtering many drugs and toxins out of the blood, storing energy for later use, helping with the absorption of certain nutrients from food, and producing substances that fight infections and control bleeding ^8.

The liver has an incredible ability to heal itself, but it can only heal itself if nothing is damaging it. Liver damage in chronic hepatitis B, if not stopped, continues until the liver becomes hardened and scarlike. This is called cirrhosis, a condition traditionally associated with alcoholism. When this happens, the liver can no longer carry out its normal functions, a condition called liver failure. The only treatment for liver failure is liver transplant. Chronic hepatitis B also can lead to a type of liver cancer known as hepatocellular carcinoma. Any of these conditions can be fatal. About 15-25 percent of people with chronic hepatitis B die of liver disease ^{9-10 .}

 The role of nurses and physicians are huge from the infection and precautionary measurement. The contemporary issues have always focused upon the diseases (Hepatitis B) prevention of several causes, but the nurses, who are the silent contributors, remained in the back of the light still today. This study effort has been drawn to take them and their contribution into the light ^{13 .}

Because of the importance of hepatitis and the prevalence of contamination with hepatitis virus, a survey of the students’ knowledge about viral hepatitis was conducted in Shiraz University of Medical Sciences. This is a descriptive study performed in cross-sectional method. Ten percent of the students enrolled in different courses were selected by stratified sampling method. A structured questionnaire was designed to obtain information about their knowledge of hepatitis.

The mean scores were 41.3±20.2 and 61±34.5 of 100 regarding knowledge about hepatitis and prevention of the disease, respectively. Students had more information about hepatitis prevention than about other aspects of the disease such as mode of transmission and symptoms. There were statistically significant differences between the knowledge of hepatitis by age, semester and educational degree (P<0.001). This study showed no significant association between knowledge of hepatitis and sex, job, parents’ education and the place of residence (P>0.05).
This study showed that students’ knowledge of hepatitis was very weak. Their knowledge with respect to the prevention of the disease was higher than other aspects.

Hepatitis can be manifested in acute form with jaundice, dark urine, anorexia, weakness, severe fatigue, pain and tender right upper quadrant (RUQ). Viral hepatitis is one of the five important infectious causes of premature death in the world. At least one million people die from hepatitis in the world yearly. About two billion patients are suffering from hepatitis B, and there are more than 350 million carriers in the world (1). Hepatitis is a preventable disease and the students of medical sciences have an effective role in its prevention. A study conducted by Al-jabar AA, et al. (2004) showed that the undergraduate medical students’ knowledge about hepatitis is low (2). The staff of health providing services should be familiar not only with treatment but also with epidemiological aspects of diseases such as transmission, prevention and control. Therefore, it is vital to study the level of information of this group in different fields including hepatitis, one of the most prevalent infectious diseases. General knowledge of health staff about viral hepatitis and its transmission and prevention can stop the spread of this disease in hospitals and in society. Since medical students are in constant contact with hepatitis patients during their studying and afterwards, they are in danger of acquiring viral hepatitis especially types B and C. The aim of this study is to determine the knowledge of students of Shiraz University of Medical Sciences and educational problems involved. In case this group’s level of information is low, they should be trained accordingly  ^{7,11,13 .}

In an analytical cross-sectional study, 356 students in different fields from eight faculties were selected by proportional stratified random sampling method. The total number of students in different departments of Shiraz University of Medical Sciences was 4025. Of all these students, based on ratio of the number of students of that department to the total number of students of the whole university, a number of students were randomly chosen. This way the departments that had more students provided more samples.  A questionnaire containing 16 items about different aspects of hepatitis was distributed among students. The questions of the questionnaire were multiple choice and based on the most reliable books on infectious diseases. The questionnaire started with questions asking the sex, age, field of studies and the academic term. The rest of the questions were specific and related to hepatitis, its transmission, prevention and symptoms. The questions in this study were about :

1-General knowledge about hepatitis, 2-Knowledge about prevention, symptoms and transmission of hepatitis A, B, C, D and E . The grades were calculated out of 100.The validity of the questionnaire was determined by specialists of infectious diseases, epidemiology and health education .The reliability (0.79) was determined by Cronbach alpha test. Data entry and statistical analysis were performed by SPSS 11.5 software. Analytic results were introduced by t-test, analysis of variance and Pearson and Spearman correlation coefficient.

The mean age of the participants in this study was 22±2.06 (Mean±SD). The maximum and minimum ages were 31 and 18, respectively. Descriptive results are presented in table 1.  The level of awareness of medical students was more than that of other groups, and this difference was statistically significant (P<0.001). The knowledge score of college students and that of BSc undergraduate students was not statistically significant (P>0.05). There was a significant difference between the mean scores in all aspects of hepatitis knowledge and different majors (P<0.001). The knowledge of medical students about this disease was more than that of occupational health, nutrition, radiology and management students (P<0.001). But their knowledge was the same as public health, nursing, dental and pharmacy students. Information level of lab science and nursing students in preventing the illness was more than that of students of other fields (72±32). There was a statistically significant correlation between students’ knowledge by age and semester (P<0.001). Therefore with increase in age and educational terms, students’ knowledge of hepatitis increased.

Development of a dedicated blood-borne viruses (BBV) team The Suffolk BBV team has increased over time from two nurse posts in 2000 to four nurses, an administrator and manager in 2008. The team was tasked with improving provision of care in the county, in particular in providing testing facilities and care to people in the more rural parts of the community, and to hard-to-reach groups such as injecting drug users. The team also sought to improve treatment referral rates and to ensure more people who commenced treatment did not leave treatment due to preventable reasons, such as long distance travel ^{20 .}

Improving referral and compliance rates When the new service was initially discussed, some local clinicians raised concerns about increasing testing and diagnosis, when the existing treatment service may not have the capacity to cope with the increased workload.

The team worked with drugs agencies, prisons and criminal justice systems (CJS) throughout the country to establish relationships with key workers and seek opportunities for joint working. It was agreed that the nurses could attend sessions that current drug users were already attending on a regular basis. The nurses offered vaccinations against hepatitis B, and later also against hepatitis A, and offered tests for hepatitis B and C and HIV ^4-6.

 It campaign to the 200 people who attended. Improving testing rates for mothers and children A dedicated BBV nurse works closely with Kerry Hoskings, the substance misuse specialist midwife in the area, to ensure all pregnant women with a history of injecting drugs are tested for hepatitis C, and also immunised against hepatitis B. It is not uncommon for babies born to drug using mothers to enter the care system, and to be placed with foster or adoptive parents. Liaising closely with social workers to ensure correct protocols are carried out is necessary – foster parents would be made aware of any testing/assessments required. There is currently a working party developing a Suffolk community guidance for professionals for children and BBVs ^{13-16 .}

This aims to signpost them to the most appropriate people to speak  to for furtherinformation, advice and support about the implications of the virus for the child’shealth and welfare. In addition, the dedicated BBV nurse also provides home visits for all pregnant women diagnosed with hepatitis B to ensure they have the appropriate information and to also be aware of the importance of babies completing a full course of hepatitis B immunization ^{5,17-19 .}

 Methodology

Limitation of the study :

The study was conducted with the objective of investigate the knowledge of Hepatitis B  management and its prevention among the staff nurses working in a medical college hospital, Dhaka. It was intended to know the  causes of Hepatitis B infection, ways of prevention and care management of Hepatitis B patient. It was good if the study compare other hospital in a wide perspective. But due to time and cost constraint the study only conducted in one hospital. The limitation of the study was the sample size. It only used 100 respondents which is not enough to generalize the findings.

Research Questions :

What is the level of knowledge on Hepatitis B virus and factors influencing Hepatitis B virus infection among the Senior Staff Nurse working in DMCH ?

Research Objectives :  

General Objectives :

To assess the level of knowledge regarding Hepatitis B virus infection among the Senior Staff Nurse.

Specific Objectives :

1.To assess the level of knowledge of the Senior Staff Nurse regarding Hepatitis  B virus infection and sign & symptoms of Hepatitis B infection.

2.To explore the knowledge level of the Senior Staff Nurse about high risk group associated with Hepatitis B virus and mode of transmission of Hepatitis B infection.

3.To know the knowledge of the Senior Staff Nurse regarding preventive  measures against Hepatitis B infection.

Study type :

Descriptive type of cross sectional study was carried out to assess the level of knowledge among the Senior Staff Nurse about Hepatitis B virus infection.

Place of study :

The place of the  study was conducted in the medicine ward  of Dhaka  Medical College Hospital, Dhaka, Bangladesh.

Study period :

The study was conducted for a period of six months starting from June 2011 to December  2012.

Study population :

Senior Staff Nurse who are serving in Dhaka  Medical College Hospital, Dhaka.

Sample size :  

There are many Senior Staff Nurse working in Dhaka  Medical College Hospital, Dhaka. But in the study 100 numbers of Senior Staff Nurses were taken as reseach samples.

Sampling Formula:

The sample size calculation follows the following formula:

   Z2 x pq

                                    d 2

Where:

n       = Sample size estimate

Z   = Z for level of significance alpha (at 0.05 level of significance value of Z is 1.96)

p= 50%

q= 1-p

d= acceptable margin of error (0.10)

Actual sample size was= 1.96 x 1.96x 0.5×0.5/0.1×0.10

= 96.04 @ 100

Sampling Technique :

 Non probability purposively sampling technique was followed for the selection of Senior Staff Nurse who are working in the medicine ward in Dhaka Medical College Hospital, Dhaka. In this sampling technique each and every individual has the equal opportunity to be included in the sample. In probability sampling there is an equal chance of samples to be selected.

Sampling selected criteria :

The Senior Staff Nurse who have completed 4 years diploma in Nursing Course. But in response to the question of availability, senior staff nurses with prior experience were selected as sampling unit.

Data Collection :

Data will be collected by interview through self administered questionnaire and observation check list.

 Inclusion criteria : 

Selected  Nurses  working  in  SBMCH.

Exclusion criteria :

Nurses  not  willing  to  participate  in  the  study.

 Conductionof the study, quality, control and monitoring:

The investigator herself was collect data from selected hospital. The collected data was checked and verified by the investigator at the end of the work every day. Any inaccuracy and inconsistency was corrected in the next working day. However, cross checking of the collected data was made randomly.

Data Processing and data analysis :

The data entry was start immediately after the completion of data collection. The collected data was checked, verified and then entered into the computer. Only fully completed datasheet was entered into the computer for the final analysis. The analysis was carried out with the help of SPSS (Statistical Package for Social Science) Windows software program.

Informed Consent :

A well and clearly understood inform consent form was filled in by the respondents and interviewer. However, translations was carried out after the according to the need of the respondents. This ensured that each of participants will get the information they need to make an informed decision.

Ethical consideration :

Prior to the commencement of this study, the research protocol was approved by the research committee (Local Ethical committee). The aims and objectives of the study along with its procedure, risks and benefits of this study was explained to the respondents in easily understandable local language and then informed consent was taken from each respondents. Then it was assured that all information and records will be kept confidential and the procedure will be used only for research purpose and the findings will be helpful for developing policy to increase the knowledge on managing Hepatitis B & its prevention  .

Variables :

 Dependent variable :

Knowledge of  the  nurses  on  Hepatitis  B  infection .

Independent variables :

• Age
• Sex
• Education
• Income
• Work experience
• Knowledge of Hepatitis B
• Causes of Hepatitis B infection
• Ways & methods of prevention  Hepatitis B infection, their symptoms and sources.
• Received Hepatitis B services from qualified providers
• Received quality services from the providers
• Reasons for not seeking Hepatitis B services from qualified providers

 Operational definition :

Hepatitis B :

Hepatitis B is an acute (sometimes fatal) form of viral hepatitis caused by a DNA virus that tends to persist in the blood serum and is transmitted by sexual contact or by transfusion or by ingestion of contaminated blood or other body fluids.

 Hepatitis B is an infectious illness caused by hepatitis B virus (HBV) which infects the liver of hominoidae, including humans, and causes an inflammation called hepatitis.

Knowledge on Hepatitis B virus :

 In this study the knowledge of the senior staff nurse working in the medicine word of SBMCH was collected about the causative agent of HBV, isolation measure, immunization of HBV, Hepatitis caused by HBV, preventive measure, sign symptoms of Hepatitis infection and sequence of infection.

High risk group of HBV infection :

The medical service providers such as doctors, nurses, technicians, word boys, admitted patients, people living with the patients, common syringe users were included.

Causes and Risk Factors of Hepatitis B :

 Hepatitis B follows a similar mode of transmission as the human immunodeficiency virus (HIV), the agent responsible for AIDS. Both are transmitted through exposure to infected blood or blood products, sexual contact and from mothers to infants primarily at birth.

However, hepatitis B appears to be far more infectious than HIV. According to the Centers for Disease Control and Prevention, approximately 30 to 40 percent of acute HBV infections in the U.S. occur in individuals with no known risk factors. In comparison, only 4 percent of AIDS cases have occurred in individuals with  known risk factors.

Hepatitis B is threatening for a variety of other reasons. In addition to the ways in which HIV is spread, hepatitis B appears to be spread by casual contact. It can be acquired by close contact within families, or from person to person through contact with open skin lesions. The virus may possibly be spread by exposure of mucous membranes to saliva, but you cannot get it from food or water, sneezing or coughing, breastfeeding, handshakes, hugs or casual contact.

Another important fact is that hepatitis B can remain stable outside the body for days or weeks, even when dry.

 Symptoms of Hepatitis B :

Symptoms and signs of hepatitis B can range from none to minimal in the early stages of the illness, to jaundice (yellowing of the skin), nausea, abdominal pain, fever, and malaise in the acute phase. Appetite loss, fatigue, itching, dark urine and pale stools are some common symptoms.

After the initial infection, carriers of hepatitis B usually have few symptoms.

Diagnosis of Hepatitis B :

Diagnosis of hepatitis B is based upon examination of the blood for characteristic antigens and antibodies associated with the disease.

Prevention of Hepatitis B :                       

 Those at greatest risk are: intravenous drug abusers; heterosexuals with multiple partners; homosexual men; health care workers; and children born to immigrants.

Two companies have a hepatitis B vaccine license for use in the U.S. and both are produced by recombinant DNA technology. As part of a national effort to eliminate hepatitis B transmission, the Advisory Committee on Immunization Practices, with the concurrence of the American Academy of Pediatrics and the American Academy of Family Physicians, has recommended that all infants receive hepatitis B vaccine as part of their childhood immunization schedule.

Three doses of vaccine are required to achieve effective immunization and will induce adequate antibody in 80 – 95 percent of persons who get three doses. The vaccination schedule most often used is three intramuscular injections, with the second and third doses administered at one to six months after the first.

The first dose of hepatitis B vaccine is given soon after birth before the infant is discharged from the hospital or in the first two months of life. The second dose is given between one and two months after the first and the third at six to 18 months of age. Since 1999, two-dose vaccines are available and required in some states for adolescents age 11 to 15 years.

Infants born to mothers infected with hepatitis B virus should be treated with hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth, with the second and third doses of vaccine given at one and six months of age.

Adults and older children should receive the injections in the deltoid. Infants should receive the injections in the thigh. Buttock injection should never be used.

 Results 

Table 1: Distribution of respondents by their gender .

 Among the respondents, most of the respondents were female and they constitute 88% of the total respondents and only 12% of the respondents were male.

Table 2: Distribution of respondents by age .

 In terms of assessing the age of the respondents, it was found that, all of the respondents belonged to the age ranging from 31 to 50 years. The total age span was divided into 2 parts and it was observed from the frequency that, 51% of the respondents were from the age group 41-50 years whereas 49% belongs to the age group of 31-40 years.

Table 3: Distribution of respondents by working hours in a day and week .

 It was significantly observed from the frequency that, all of the respondent, have to work 8 hours in a day and 6 days in a week.

Table 4: Distribution of respondents by knowledge of Hepatitis B infection .

 To know about the knowledge of respondents about cause of Hepatitis B, the study finds that 95% of the respondents possess the knowledge about the Hepatitis B infection but only 5% of the respondents are not familiar with Hepatitis B infection.

Table 5: Cause of Hepatitis B infection .                       

Almost 95% respondents believe that, patient has suffered Hepatitis B infection due to unsafe blood transfusion, sexual relation, from needle pricks or Blood transfer. Only 5% thinks that it is happened only due to sexual relation.

Table 6: knowledge about the prevention of Hepatitis B infection .

 In terms of assessing the knowledge about the prevention of Hepatitis B infection, all of the respondents noted that, they know the way of prevention of Hepatitis B infection.

Table 7: knowledge about name of the ways of prevention of Hepatitis B infection .

 For corresponding the name of the ways to prevent Hepatitis B, all of respondent told that they know the way of prevention of Hepatitis B infection. Such as vaccination, screening blood before transfer, avoid of needle sharing, proper sterilization, proper use of condom, gloves, etc.

Table 8: knowledge about who are the commonly infected with Hepatitis B.

 Respondents were questioned that whether they know who are commonly infected with Hepatitis B, and in response to this question, all of the respondents noted that they know about the victims who are the infected with Hepatitis B.

 Table 9: knowledge about common symptoms of Hepatitis B .

 All of the respondents distinguished that they know the common symptoms about Hepatitis B and they also demonstrated that Hepatitis B have some of the common symptoms like malaise, weakness, anorexia, nausea, vomiting, jaundice, abdominal pain, headache etc.

 Table 10: Knowledge about the signs of Hepatitis B .

All of the respondents notified that they are familiar to the signs of Hepatitis B and in most of the cases ; patients are found infected by HBS positive in most cases. Hepatomegaly, increased ingestion problem, jaundice, change in eye’s color, conversion of the color of nail into yellow, liver small in size are some of the signs of Hepatitis B as illustrated by the respondents.

Table 11: knowledge about mechanism of preventing Hepatitis B in hospital .

All respondents unanimously told that they know about the mechanism of preventing Hepatitis B in Hospitals. Besides, respondents also noted that the methods are Autoclave, Hot air oven, chemical disinfectant like savlon, boiling, decontamination  etc.

Table 12: knowledge about care management of Hepatitis B in hospital .

100% of the respondents told that they know about care management of Hepatitis B patient.  Majority respondents believe that carefully wear hand gloves during operation, taking care of the patients, taking precaution during blood transfusion / injection, handle the patient etc. can help to promote quality of care for Hepatitis B patients in hospitals.

Table 13: Distribution of maintains the precaution to prevent Hepatitis B infection .

All of the respondents urged that they used to maintain the precaution to prevent Hepatitis B infection.

Table 14: Distribution of the system for preventing Hepatitis B in hospital .

While mentioning about the system of preventing Hepatitis B in hospitals, the 86% of the respondents informed that isolated OT and post operative ward and separate provision of wards can prevent Hepatitis B in the hospitals. 4% of the respondents pointed up that cleanliness in surgical aspects can help preventing Hepatitis B in the hospitals. 5% of the respondents also noted the necessity of proper disposal of sharp instruments as the preventive measures whereas proper use of disposal as a measure has been supported by 5% of the respondents.

Table 15: Wearing mask and cap while working period

To examine the practice of wearing of masks and cap during working period, it was found from the study that 51% of the respondents mentioned that they used to wear mask and caps during the working period and more specifically during operation and patients clinical service. They also told that, it is necessary to prevent themselves for infections and germs during the clinical services to the patients. Only 49% of the respondents told that, they not in all cases wear mask or use cap during their working period

Table 16: Distribution of the respondents by educational level and gender.

 In order to assess the knowledge about Hepatitis B, in line with level of education and gender relations. It was also significant that, only 38 respondents have BSc & Public health Nursing who were all female and know about Hepatitis B.

The bar chart describes respondent’s education level, whereby it is showed that 100% nurses have passed SSC. All are  get diploma in nursing .Only 70% nurses are diploma in midwifery.

To figure out respondent’s further study after basic degree, it was observed that only 9% of the respondents have studied after basic degree. It was really surprising that more than 91% of the respondents didn’t have the opportunity to study further.

This pie chart describes the status of training received by the respondents during their job. It was noted that only 18% of the respondents have received training during on job, whereas 82% did not have any training.

While assessing the knowledge of the respondents about Hepatitis B infection and its prevention, it was observed that, 90% of the respondents are familiar with the Hepatitis B infection and its prevention and only 10% of the respondents are ignorant about it.

 In case of measuring the common victims of Hepatitis B, the study finds that, children are prone to Hepatitis B while 52% respondents think them to be infected by Hepatitis B. Respondents also urged that, drug addicted person may also be prone to Hepatitis B, which was supported by more than 43% of the respondents. Only 5% of the respondents assumed that most of the prostitutes are infected by Hepatitis B.

 While understanding the use of antiseptic for surgical dresses, it was derived from the respondent’s opinion that, 85% of the respondents use Methylated Spirit for surgical dress and only 15% of the respondents use Iodine for surgical dresses.

 To assess the knowledge about the guideline for Hepatitis B infection prevention, it was observed that, 33 respondents out of 100 respondents have the knowledge about the Hepatitis B infection prevention and 67 respondents do not have knowledge about the guideline for Hepatitis B infection prevention. In response to the query for knowing how far the knowledge about guideline is followed, it was observed from the study that 25 respondents out of 33 respondents, who have the knowledge about the Hepatitis B infection prevention follows the guidelines, rest of the 8 respondents were found not following the guideline prescribed for Hepatitis B infection prevention.

In response to the query for any special training received by respondents, 22% respondent mentioned that they have special training for Hepatitis B infection prevention while 2% of the respondents did not receive any special training on Hepatitis B prevention.

It was evident from the study finding that, 56% of the respondents mentioned that the hospital management doesn’t taken regular discussion/ seminar/ refresher training on hospital acquired infection with all staff, while 44% respondents mentioned that hospital management holds discussions on acquired infections which may contribute to increase the knowledge of the respondents to Hepatitis B prevention.  ge of Hepatitis B infection and notably 12% marked it as not so necessary.

In response to the question of whether the respondents use any material for counseling the Hepatitis B infected patients, most of the patients (75%) pointed out that they use BCC materials for counseling the Hepatitis B patients, whereas 25% of respondents do not use due to lack of supply of BCC materials and other reasons.

Discussion:

The study findings suggested that most of the respondents were female senior staff nurse. They constitute 88% of the total respondents and only 12% of the nurses were male.  In terms of assessing the age of the respondents, it was found that, all of the respondents belong to the age ranging from 31 to 50 years whereby, 51% of the respondents were from the age group 41-50 years. 100%  nurses have education level up to SSC & all are get diploma in nursing. Only 70% nurses are  diploma in midwifery.  It was also observed that only 9% of the respondents have studied after basic degree and only 18% of the respondents have received training during on job, It was significantly observed from the frequency that, all of the respondents  here, have to work 8 hours in a day and 6 days in a week. The study also finds that, 90% of the respondents are familiar with the Hepatitis B infection and its prevention and only 10% of the respondents are ignorant about it. 95% of the respondents possess the knowledge about the Hepatitis B infection. Besides, almost 95% respondents believe that, patient has suffered Hepatitis B infection due to unsafe blood transfusion, sexual relation, from needle pricks or Blood transfer. Only 5 percent thinks that it is happened only due to sexual relation. It was also interesting to find that, all of the respondents noted that, they know the way of prevention of Hepatitis B infection, such as vaccination,  screening blood before transfer, avoid of needle sharing, proper sterilization, condom, g loves, etc. ( Ref. tab. 1-7, fig. 1-4 ).

All of the respondents urged that they know about the victims who are the infected with Hepatitis B. In case of measuring the common victims of Hepatitis B, the study finds that, children are prone to Hepatitis B while 52% respondents think them to be infected by Hepatitis B. Respondents also urged that, drug addicted person may also be prone to Hepatitis B, which was supported by more than 43% of the respondents. Only 5% of the respondents assumed that most of the prostitutes are infected by Hepatitis B. Respondents distinguished that they know the common symptoms about Hepatitis B and they also demonstrated that Hepatitis B have some of the common symptoms like malaise, weakness, anorexia, nausea, vomiting, jaundice, abdominal pain, headache etc. (Ref. tab. 8-9, fig.5. )

Respondents notified that they are familiar to the signs of Hepatitis B and in most of the cases; patients are found infected by HBS positive in most cases. Hepatomegaly, increased ingestion problem, jaundice, change in eye’s color, conversion of the color of nail into yellow, liver small in size are some of the signs of Hepatitis B respondents illustrated. Respondents unanimously told that they know about the mechanism of preventing Hepatitis B in Hospitals. Besides, respondents also noted that the methods are autoclave, Hot air oven, chemical disinfection like Savlon, Boiling, Chlorine etc. 100% of the respondents told that they know about care management of Hepatitis B patients. (Ref. tab. 10-12 ).

Majority respondents believe that carefully wear hand gloves during operation, taking care of the patients, taking precaution during blood transfusion/injection, handling the patient etc. can help to promote quality of care for Hepatitis B patients in hospitals. It was also urged by the respondents that they used to maintain the precaution to prevent Hepatitis B infection. While mentioning about the system of preventing Hepatitis B in hospitals, respondents informed that isolated  OT and post operative ward and separate provision of wards can prevent Hepatitis B in the hospitals. Some of the respondents pointed up that cleanliness in surgical aspects can help preventing Hepatitis B in the hospitals. 5% of the  respondents also noted the necessity of proper disposal of sharp instruments as the preventive measures whereas proper use of disposal as a measure has been supported by 5% of the respondents. It was derived from the respondent’s opinion that, use of Methylated Spirit or Iodine for surgical dress. (Ref. tab. 13-14, fig.6 )

To examine the practice of wearing of masks and cap during working period, it was found from the study that 51% of the respondents mentioned that they used to wear mask and caps during the working period and more specifically during operation and patients clinical  service. Only 49% of the respondents told that, they not in all cases wear mask or use cap during their working period. To assess the knowledge about the guideline for Hepatitis B infection prevention, it was observed that, 33 respondents out of 100 respondents have the knowledge about the Hepatitis B infection prevention and 67 respondents do not have knowledge about the guideline for Hepatitis B infection prevention. In response to the query for knowing how far the knowledge about guideline is followed, it was observed from the study that 25 respondents out of 33 respondents, who have the knowledge about the Hepatitis B infection prevention follows the guidelines. 78 percent respondents mentioned that they have special training for Hepatitis B infection prevention. (Ref. tab. 15, fig.7 ).

 It was also significant that, only 38 respondents have BSc % public health  nursing who were all female and know about Hepatitis B. In response to the query 78% respondents mentioned that they have special training for hapatitis B infection prevention while 22% of the respondents did not receive any special training on Hepatitis B prevention. It was evident from the study finding that, 56% of the respondents mentioned that the hospital management doesn’t taken regular discussion/ seminar/ refresher training on hospital acquired infection with all staff, while 44% respondents mentioned that the hospital management holds discussions on acquired infections which may contribute to increase the knowledge of the respondents to Hepatitis B prevention.    88% respondents think regular training or class should be necessary to increase knowledgeof Hepatitis B infection.

Most of the patients pointed out that they use BCC materials for counseling the Hepatitis B patients, sometimes; it becomes problematic, due to lack of supply of BCC materials and other reasons. Thus it is necessary to ensure better understanding about the signs, symptoms and skill training for the nurses.

( Ref. tab. 16  fig.8-11.)

Conclusion:

The study unfolds that, Hepatitis B is an infectious illness which has become epidemic and transmission of hepatitis B virus results from exposure to infectious blood or body fluid and in most of the cases, the signs and symptoms of Hepatitis B are dialectic. So, proper and timely identification of it can help ensuring the treatment to the fatal disease. Role of nurses is evident in the case of Hepatitis B patients and preventing its transmission.  Through an understanding of the serologic markers, a nurse-midwife can identify those clients or risky groups who are at risk for transmitting hepatitis B. Once identified, the necessary preventative measures can be taken to interrupt the disease process. Nurses can play a role in preventing prevalence of Hepatitis B among children and other risk group who are infected with HBV by suggesting the treatment methods. It is till a matter of hope that ensuring the proper treatment and the vaccine together can ensure in prevention of transmission the disease in 80-90 percent of cases, whereby nurses can be the major stakeholders for prevention of the fatal diseases. Apart from these, it can be undoubtedly said that, the level of knowledge and the expertise of the nurses can play a vital role for identification, prevention and cure of the Hepatitis B patients with a proper focus on the health safety.

Thus proper training and instrumental support needs to be provided to the nurses to block this unwanted and devastating silent killer disease.

 Recommendation:

1. 1.    Most of the nurses are familiar with the Hepatitis B infection and its prevention and believe that, patient has suffered Hepatitis B infection due to unsafe blood transfusion, sexual relation, from needle pricks or Blood transfer, so careful measurements should be taken to prevent Hepatitis B patients.
2. Hepatitis B have some of the common symptoms like malaise, weakness, anorexia, nausea, vomiting, jaundice, abdominal pain, headache etc. and signs like hepatomegaly, increased ingestion problem, jaundice, change in eye’s color, conversion of the color of nail into yellow, liver small in size. So immediate medical care or treatment facilities needs to be ensured as soon as possible.
3. 3.    As Hepatitis B infection are mainly the infected among children, drug addicted or prostitutes, special attention and form of care should be ensured for them prevent and recover from diseases.
4. 4.    The mechanism of preventing Hepatitis B in includes some methods, which are cleanliness in surgical aspects autoclave, Hot air oven, chemical disinfection like Savlon, Boiling, Chlorine etc, taking precaution during blood transfusion / injection, handling the patient etc. that can help to promote quality of care and so measures like Vaccination,  screening blood before transfer, avoid of needle sharing, proper sterilization, condom, gloves, should be ensured.

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20. Janet Catt, Lead Blood-borne Viruses (BBV) Nurse, Suffolk Primary Care Trust (PCT), Mr Adrian Kirkby, County Harm Reduction Manager, Maggie Panou, Helen Kniveton, Ann Mayhew………………