Commentary: the importance of education and vaccination in reducing the risk of hepatitis infection among nursing students


  • Commentary on: Nursing students' immunisation status and knowledge about viral hepatitis in Turkey: a multi-centre cross-sectional study. [Yamazhan et al. 2011, in this issue, 58 (2)].


CUTTER J. (2011) Commentary: the importance of education and vaccination in reducing the risk of hepatitis infection among nursing students. International Nursing Review58, 186–187

Background:  Healthcare workers are at risk of contracting blood-borne viral infection during contact with blood and body fluids. Nursing students may be at particular risk because of their inexperience. Adoption of suitable precautions, hepatitis B vaccination and appropriate post-exposure prophylaxis will significantly reduce the risk of infection.

Aim:  This commentary puts into context the findings of a study by Yamazhan et al. who explored nursing students' knowledge on hepatitis together with their immunization status.

Evaluation:  Knowledge of hepatitis, its mode of transmission and the risks of infection following adverse exposure to blood and body fluids are essential to ensure safe practice. This paper identifies that nursing students' knowledge of hepatitis is moderate only and varies between universities. However, the uptake of hepatitis B vaccination among the sample was high, suggesting a high commitment to reducing the risk of this infection by the universities and clinical placements.

Implications:  This paper highlights the need for a standardized education package to be developed and delivered by all universities in Turkey to ensure that nursing students have a sound knowledge of hepatitis and other blood-borne infections. Vaccination programmes must continue to ensure that nursing students are protected from hepatitis B.

In this edition of INR, Yamazhan et al. (2011) publish their study on nursing students' immunization status and knowledge of viral hepatitis in Turkey. The study achieved a response rate of 83.2% and a sample size of 1491, representing nursing students from 14 out of 47 nursing schools in Turkey. The need for awareness of the risks of hepatitis was highlighted by the World Health Organization (WHO) who suggests that sharps' injuries may have accounted for approximately 66 000 cases of hepatitis B virus (HBV), 16 000 cases of hepatitis C virus (HCV) and 200–5000 cases of human immunodeficiency virus (HIV) annually in healthcare workers worldwide (Prüss-Üstün et al. 2003). This estimate, based on numbers of at-risk healthcare workers, the average numbers of sharps' injuries sustained annually, the prevalence of infection, HBV vaccine rates and post-exposure prophylaxis take up, reinforces concerns that healthcare workers are at risk of occupationally acquired blood-borne viral infection. Nursing students may be particularly prone to sustaining sharps' injuries because of their inexperience and this is supported by this study in which 28.1% of students had sustained a sharps' injury. The actual number could be higher than this as students may be reluctant to report injuries because of fear of censure and concerns about future employment.

The study demonstrated that overall scores relating to knowledge of hepatitis were only moderate, although it was identified that there were considerable variations in scores between nursing schools attributed to the lack of a standardized educational programme in Turkey. There is no reason to assume that these findings are not representative of the situation outside Turkey. It is important that students are both knowledgeable about hepatitis and retain an acute awareness of the risk of hepatitis following sharps' injuries. Moreover, the risks of HIV infection cannot be ignored and should be incorporated into teaching packages. The correct action required to prevent sharps' injuries and to reduce the risk of infection in the event of such an injury must be continually reinforced.

The vaccination of healthcare workers is effective in reducing the risk of occupational acquisition of HBV infection [Department of Health (DOH) 2011]. Among the sample, 85% were vaccinated against HBV and 9.1% against hepatitis A virus. This compares favourably with many other countries. Although there is no vaccine against HCV and HIV, prompt attention following exposure to infected blood will allow effective post-exposure prophylaxis to be administered to reduce the likelihood of contracting HIV infection (DOH 2008), and allows monitoring and early detection of HCV infection and the prompt administration of suitable treatment (Wiegand et al. 2008).

However, accessing appropriate treatment relies on reporting the injury and checking the blood-borne viral status of the source patient. Previous studies have demonstrated that compliance with reporting is poor (Shiao et al. 2002; Smith & Leggat 2005), yet Yamazhan et al. (2011) found a reporting rate of almost 90% among their sample. This is highly commendable and reflects the importance placed on correct follow-up of these injuries by both the clinical placements and the participating universities.

Of course, there are limitations within this study and these have been acknowledged by the authors. Only 14/47 universities were represented, leading to questions concerning the possibility of non-response bias and the generalizability of the findings. Furthermore, the study relied on self-reported data which carry a risk of bias because of the social desirability response. This may be particularly prevalent among students, who are likely to be eager to please their lecturers. Nevertheless, there is no reason to suppose that the experiences of students in the participating nursing schools are atypical of universities in Turkey and elsewhere.

A key recommendation of this study is that the curricula of all nursing schools should be standardized. According to 83.0% of respondents in this study, university education was their most important source of knowledge. It is therefore essential that it is right. Comprehensive infection control educational packages must be developed for delivery across all nursing programmes irrespective of their location.

However, education alone is not enough. Without a commitment to safety, provision of appropriate personal protective equipment and safety devices, access to staff health services and appropriate vaccination, and post-exposure prophylaxis, education will not significantly reduce the incidence of sharps' injuries and the resulting risk of blood-borne viral infection. Therefore, it is important that students are supported adequately while in clinical practice and have access to a comprehensive staff health programme.

This study provides a welcome addition to the available information on the role of education in ensuring the safety of nursing students. While the subject has been widely researched among qualified healthcare professionals, relatively few studies have included students. The risk of occupationally acquired blood-borne viral infection is significant and reducing these risks requires a multifaceted approach. Yamazhan et al. (2011) have identified the need to develop education and encourage the appropriate action following exposure to potentially infected blood. Now others must follow their example.