Hepatitis B and C seropositivity among nursing students at a Turkish university
Bora Ekinci, Mugla Universitesi, Mugla Saglik Yuksekokulu, Mugla, 48000, Turkey; Tel: 90-252-211-2232; Fax: 90-252-212-4755; E-mail: firstname.lastname@example.org; email@example.com.
IRMAK Z., EKINCI B. & AKGUL A.F. (2010) Hepatitis B and C seropositivity among nursing students at a Turkish university. International Nursing Review57, 365–369
Background: Viral hepatitis infections are major health problems, which are especially prevalent in developing countries. In particular, health care workers are at high risk for contracting viral hepatitis. Therefore, preventive measures to minimize occupational exposure to blood borne pathogens are needed to protect both health care workers and nursing students.
Objectives: To determine the prevalence of Hepatitis B and C infections and risk factors among nursing students.
Methods: Venous bloods were obtained from nursing students and were serologically tested using the ELISA method. A questionnaire form was also used to obtain data related to demographic and socio-economic characteristics of the participants.
Results: 0.7% of the nursing students were serologically positive for HBsAg, 17.0% for Anti-HBs and 7.5% were positive for Anti-HBc (IgG). No statistical relationship was determined between all independent variables and the results of serologic tests.
Hepatitis B (HBV) and hepatitis C (HCV) infections are major health problems throughout the world and especially in developing countries such as Turkey. The World Health Organization (WHO) estimated that there were 360 million chronically HBV-infected people and 5.7 million HBV-related cases worldwide (World Health Organization 2007). HCV infections are also common worldwide. It is estimated that about 3% of the world's population carry HCV (WHO 2002). According to many studies conducted in Turkey in the normal population, the mean prevalence rate of hepatitis B surface antigen (HBsAg) was detected as 6.8% (2.0–14.3%). Results at several blood transfusion centres showed the anti-HCV positivity rate as 0.58% (0–2.1%) (Mıstık & Balık 2002).
The HBV and HCV acute infections can be fatal and cause viral chronic infections as well as chronic liver diseases and hepatocellular carcinoma (Kottilil et al. 2005). In hospital environments, health care workers (HCWs) are likely to suffer from occupational exposures to body fluids or blood-borne pathogens (BBPs) such as HBV, HCV and human immunodeficiency virus (Dement et al. 2004; Özsoy et al. 2003; Tarantola et al. 2006). HCWs may therefore be at risk for hepatitis infections. Various means of exposure can involve a needlestick or sharp object injury, contact of mucous membrane or abraded skin with blood, tissue or other body fluids which are potentially infectious. In addition to infectious fluids, semen and vaginal secretions are also considered potentially infectious but have not been implicated in occupational transmission from patients to HCW (Centers for Disease Control and Prevention 2001; Rantala & van de Laar 2008; Shepard et al. 2006).
The Centers for Disease Control's (CDC) universal precautions (CDC 1987) and Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogens (BBP) standard (OSHA 2001a,b) are intended to prevent exposure of HCWs to BBPs in order to minimize the risk of occupational exposure to BBPs. The recommendations of the CDC (CDC 1987) and OSHA (OSHA 2001a,b) must be implemented for all HCWs to minimize exposure to BBPs. HCWs should be educated concerning the risk for and prevention of blood-borne infections, including the need to be vaccinated against hepatitis B. General measures for prevention and control include avoiding contact with infectious blood and secretions, being scrupulously careful in the use and disposal of needles and other sharp instruments, appropriate use of hand washing and protective barriers (CDC 1987, 2001; OSHA 2001b).
Although HCWs and especially nurses are at risk for occupational exposure to BBPs (İlhan et al. 2006; Özsoy et al. 2003), student nurses might be at a greater risk because of their clinical inexperience (Shiao et al. 2002). Previous studies have shown that medical (Öncü et al. 2005) and nursing students (Lin et al. 2007; Talas 2009) need to be vaccinated against hepatitis B and to implement universal precautions. Determining the risk factors for acquisition of these infections and the prevalence of HBV and HCV in nursing students are important in planning for any intervention in controlling these infections.
The main objectives of the study were to determine the prevalence of HBV and HCV among nursing students in a university in Turkey and to determine the risk factors responsible for causing these infections.
Materials and methods
This descriptive cross-sectional study was conducted between April and May 2006 in a university in Turkey. There were a total of 223 nursing students (excluding fourth class students) in the spring period of the year 2006. 147 voluntary students (65.9%) who had completed serological tests were recruited for the study. Fourth class students were excluded from the study because of inadequate communication regarding their community health training practices; estimable data could not be obtained.
The study protocol was approved by the university director and school manager. According to the Declaration of Helsinki, written informed consent was designed and obtained from all participants. The purpose of the study was explained in detail. The personal data of the participants were recorded and not shared with third parties. When the study started, all participants were continuing clinical training at the hospitals and other health institutes.
A structured questionnaire was used to obtain data related to demographic and socio-economic characteristics of the participants. The questionnaire included questions regarding age, gender, number of household members, history of living conditions at the dormitory or in the family, history of HBV and HCV infection of themselves and their household members, vaccination, occupational needle stick injury, any nursing care given to patients with HBV and HCV infection, history of risky sexual behaviour and whether participants had piercings or tattoos.
Venous blood samples were taken from all participants at the laboratory of Mugla City Hospital. The HBsAg, hepatitis B surface antibody (anti-HBs), hepatitis B core antibody [anti-HBc (IgG)] and anti-HCV markers were serologically tested with enzyme linked immunosorbent assay (ELISA) method (General Biologicals Corp., Hsin-Chu, Taiwan). Fisher's exact and Pearson chi-square tests were used to determine the significant differences between categorical variables. Statistical significance value was taken as p < 0.05.
Female students comprised 69.4% of the group (102 of 147) and 30.6% of them were male with an average age of 21.12 ± 1.74. The obtained ratios for hepatitis B infection history, counts of households >4, living in a dormitory, HBV infection in the family and HBV vaccination were 2.0, 59.9, 93.9, 2.7 and 17.7%, respectively. In the estimation of exposure to risky factors for transmission of hepatitis, 9.5% of the students reported needlestick injury, 17.0% gave health care to infected patients, 2% of them had risky sexual relations and 1.4% of them indicated a piercing or tattoo. Twenty-six students (17.7%) stated they had received a HBV immunization, but 11 (7.5%) of 26 students were found as negative for anti-HBs (Table 1). Neither the students nor their family members indicated any HCV infection history.
Table 1. Relation between risk factors and anti-HBc (IgG)
|Sex|| || || || |
| Female||102 (69.4)||6 (5.9)||0.267*||0.362|
| Male||45 (30.6)||5 (11.0)|| || |
|Family members|| || || || |
| ≤4||59 (40.1)||3 (5)||0.526||0.267|
| >4||88 (59.9)||8 (9)|| || |
|Housing|| || || || |
| Family||9 (6.1)||–||1.000||0.941|
| Dormitory/pension||138 (93.9)||11 (7.8)|| || |
|HBV infection history|| || || || |
| Yes||3 (2.0)||1 (33.3)||0.209||0.999|
| No||144 (98.0)||10 (6.9)|| || |
|HBV infection history within family|| || || || |
| Yes||4 (2.7)||–||1.000||1.000|
| No||143 (97.3)||11 (7.7)|| || |
|Vaccination|| || || || |
| Yes||26 (17.7)||2 (7.7)||1.000||0.050|
| No||121 (82.3)||9 (7.4)|| || |
|Needlestick injury|| || || || |
| Yes||14 (9.5)||1 (71)||1.000||0.052|
| No||133 (90.5)||10 (75)|| || |
|Giving health care to patients|| || || || |
| Yes||25 (17.0)||–||0.212||0.965|
| No||122 (83.0)||11 (9.0)|| || |
|Risky sexual relation|| || || || |
| Yes||3 (2.0)||–||1.000||0.931|
| No||144 (98.0)||1 (7.6)|| || |
|Piercing/tattoo|| || || || |
| Yes||2 (1.4)||–||1.000||0.938|
| No||145 (98.6)||11 (7.6)|| || |
No statistically significant relationship was found to exist between all independent variables and anti-HBc (IgG) positivity (Table 1). When gathered data were estimated for anti-HBs, similar relations were found (P > 0.05) (vaccinated students were excluded for evaluation of these criteria).
Besides these results, 0.7% of the students were serologically positive for HBsAg. Twenty-five students (17.0%) and 7.5% of the students were found to be positive for anti-HBs and anti-HBc (IgG), respectively. However, 10 (6.8%) of 25 students (17.0%) reported that they had never been given HBV vaccine. One serologically HBsAg positive student was also positive for anti-HBc (IgG). All of the participants were negative for HCV (Table 2).
Table 2. Positive serologic test results for hepatitis B and C virus infection patterns (total n = 147)
In terms of chronic HBV infection, prevalence rates have been categorized into three regions of the world as low (<2%), moderate (2–7%) and high endemic (≥8%) (WHO 2002, 2007). According to research regarding HBV prevalence in Turkey, it has been estimated as a moderately endemic area (Güven et al. 2006; WHO 2002). According to previous studies among the normal population the mean range of HBs-Ag seroprevalance and anti-HBs prevalence were reported as 6.8% (2.0–14.3%) and 29.7% (15.8–50.0%), respectively (Mıstık & Balık 2002). Among HCWs the positive ratio for HBs-Ag was found to be 3.0% in Turkey by Özsoy et al. (2003) and 2.0% by Ersöz et al. (2006).
Our research showed the HBs-Ag positivity to be 0.7%, and anti-HBs were 17.0% in which 10 of 147 (6.8%) was exposed to HBV. Furthermore, the anti-HBc (IgG) results were 7.5% (11 students) among nursing students (Table 1), and no HCV infection was detected. Nevertheless, no association was proved between anti-HBc (IgG) serologic positivity and risk factors about HBV infection. Risk factors included gender, counts of households, housing, HBV infection history in their family, immunization, needlestick injury, caring of patients with hepatitis, risky sexual relations, tattoos and piercings (Table 1) (P > 0.05).
HBsAg was detected by ELISA in one (0.7%) student in our study. Öncü et al. (2005) reported HBsAg and anti-HBc (IgG) prevalence as 2 and 7.3%, respectively, among 247 medical school students in Turkey. In the same study, 13 students (5.3%) were found to be anti-HBs positive because of natural exposure to HBV infection (Öncü et al. 2005). Similar to these findings, Lin et al. (2007) in Taiwan found HBsAg prevalence at a ratio of 2.1% among nursing students. Other findings from the Royal Thai Army nursing students in Thailand by Pilakisiri et al. (2009) reported HBV and HCV seroprevalence rate as 10.8% and 0.5%, respectively, among 381 nursing students. Besides those reported findings our data showed that HBsAg positivity among nursing students was low. In Turkey, both compliance with universal precautions and application of the HBV vaccination schedule decreased the HBsAg seroprevalence rate of HCWs (Özsoy et al. 2003). Nevertheless, the prevalence rate among HCWs was higher than for nursing students (Mıstık & Balık 2002). The probable reason may be attributed to the fact that the students were undergoing training and not yet giving full health care to hepatitis patients where they would be exposed to occupational risks. As reported in previous studies, the HBV infection occurs mostly by contact with infected blood or body fluids rather than exposure to patients (Güven et al. 2006; Uzun et al. 2008). In this study only 17.0% of the students stated they had provided nursing services to HBV patients, but 9.5% of them had a history of needle-stick injury. In some previous reports related to both HBV infection and medical school students, risk factors which were supposed to be causative such as needlestick injuries (Pido & Kagimu 2005) and risky sexual behaviours (Öncü et al. 2005; Pido & Kagimu 2005) were not found to be factors in this research. Another probable factor for HBV infection is sexual intercourse with persons working in the sex industry (Akçam 2003; Mıstık & Balık 2002). In this research most of the participants were female (69.4%). For cultural and conventional reasons, considerable numbers of young people, especially females, experience sexual intercourse to a lesser extent by waiting until marriage in Turkey (Öncü et al. 2005).
Anti-HCV positivity was not detected in venous blood samples of nursing students. According to different studies conducted in Turkey among HCWs, HCV infection was not even detected (Kuruüzüm et al. 2008) or was determined to be a low rate of 0.3% (Özsoy et al. 2003) and 0.4% (Ersöz et al. 2006). In a report by Trevisan et al. (2005) from Italy, the anti HCV positive ratio was detected as 0.3%. According to these results HCV infection is unlikely to be an important health issue among HCWs and students but preventive methods and education programs must be promoted and maintained in order to eliminate spreading the HCV infection.
Although, in Turkey, HBV immunization is free of charge for HCWs and nursing students, only 17.7% of them indicated that they had been immunized. Still, 7.5% (11 students) of immunized students were detected as serologically negative for anti-HBs and considered not to be vaccinated. Öncü et al. (2005) performed a similar study among medical students and found the vaccination rate as 38.5% in Turkey. These results suggested that the majority of nursing students have not understood the importance of hepatitis infection and vaccination. Regardless of who they were, they were still unaware of the emergence of HBV infection. However, in a previous research reported from Australia by Smith & Leggat (2005), three doses of the HBV immunization were enough to increase the rate of those protected from infection from 46.2 to 96.2% in a three-year vaccination program among 274 nursing school students.
Finally, in the hospital environment, while nursing students gave health care to a risky group of patients, they might have been exposed to infectious blood and body fluids because only 17.7% of them had been immunized with HBV vaccine. At the end of this research, serologically negative students were immunized with three doses of hepatitis B vaccine.
The data from our study showed us that increasing efforts should be undertaken to overcome blood-borne infections like viral hepatitis. Before undergoing nurse training in clinical settings, compliance in the use of universal precautions and safety enhanced devices combined with an effective vaccination program against HBV must be carried out. Lastly, in order to raise nursing students' awareness and protect them from viral hepatitis infections, students must be mandated to consistently abide by universal precautions regarding procedures and care of their patients.
We would like to thank to Atilla Goktas, PhD (Department of Statistics, Art and Science Faculty, Mugla University, Mugla-Turkey) for the analysis of the power values.
Zohre Irmak was involved in the study conception, drafting of manuscript, statistical expertise and data collection. Bora Ekinci was involved in the study design, drafting of manuscript and data collection. Ayse Ferhan Akgul provided material support and analysis.