Pak J Med Res Original Article Vol. 51, No. 3, 2012

Knowledge, Attitude and Practices of Dentists about Hepatitis B and C Infection in

Asia Batool, Misbah Ul Islam Khan Sherwani, Khatoon Akhtar Bano, Muhammad Aasim PMRC Research Centre, Fatima Jinnah Medical College, Lahore.

Abstract

Objectives: To assess the knowledge, attitude and practices of dentists of public and private sector in Lahore about Hepatitis B and C infection. Study type and settings: This cross-sectional analytical study was conducted on private dental practitioners and public sector dental surgeons working in of Lahore. Subjects and Methods: Private sector dentists of Lahore working in Shahdara, Badami Bagh, Mughalpura, Baghbanpura, Gulberg, Shadman, Mozang, Feroz pur Road, Model Town, Multan Road, Johar Town and Tohkher Niaz Baig were selected for the study. In the public sector hospitals, dental surgeons were selected from Demont Morency Dental College and , , , Govt. Mozang Hospital, Jinnah Hospital, , Mian Munshi Hospital, Sheikh Zaid Hospital, Railway Hospital, and Combined Military Hospital by using convenient sampling technique. A self-administered, close-ended questionnaire was used and information was gathered about their knowledge, attitude and practices for HBV/HCV infection and its prevention. Data was entered in the SPSS-13 computer program. Frequency and percentages were calculated for different segments and comparison between the two groups was performed by using z-test for proportion. p-value ≤0.05 was considered significant. Results: A total of 209 dentisits agreed to participate in the study (105 in private and 104 in public sector). The mean age of the respondents was 33+9.8. Although majority had good knowledge about these viruses, their spread and prevention but information was either lacking or was wrong in many dentists. Disease spread through close contact was thought by 35%, through mosquitoes by 15%, in closed environments by 8%. Sexual and perinatal transmission of these viruses was not known by 30% and 8% did not know that these can be transmitted by blood or unsterilized instruments. About 50% stated that B and C cases should be restricted from working in food industry. Vaccine for hepatitis B was not known in 7%, while 25% said that a vaccine is available for hepatitis C. Attitude evaluation highlighted that 98% dentitsts screened their patients for hepatitis-B and C prior to dental treatment and 80% gave virus positive patients the last appointment to prevent disease transmission. Alomost 52% agreed that virus infected health professionals should not be discouraged from treating patients. Deficiencies were observed in the dental practices, which were more common in public sector like not being vaccinated for hepatitis B, infrequent use of special containers to dispose sharps. Deficiencies more marked in private sector included infrequent hand washing, not using autoclave for sterilization, not using new forceps/handpiece or personel protective equipments (mask/eye face shield). Conclusions: There were deficiencies in the knowledge, attitude and practices about hepatitis B&C virus in dentists of both public and private sector which need to be addressed on priority basis to stop disease transmission from this very frequented site. Policy message: Provision of a continuous formal and obligatory education on hepatitis B and C regarding its nature, causative organisims, risk factors, diagnosis management and prevention to update in infection control practices. The Dental Association should be made partner in the infection control campaign. Key words: KAP study, dentists, public and private sector, hepatitis B&C virus.

Introduction health care workers and their patients1. Dental care professionals are at an increased risk of cross infection as 2,3 ith the global rise in the number of people well as its transmission while treating patients . With W infected with hepatitis B and C viruses, cross the presence of people who are infected with hepatitis B infection has become a paramount concern to dental and C and the HIV viruses, cross infection has become a major concern both to the dentist and his patient2. Both Corresponding Author: viruses can be transmitted after needle stick injuries and Asia Batool contact with body secretions and also because many PMRC Research Centre infected patients are unaware of their status or not willing Fatima Jinnah Medical College to disclose their disease status to health care workers. Lahore. There have been several reports of HBV and HCV Email: [email protected]

Pakistan Journal of Medical Research, 2012 (July - September) 93 Knowledge, Attitude and Practices of Dentists about Hepatitis B and C Infection in Lahore transmission to patients from surgeons despite the surgeons were selected from Demont Morency Dental development of the universal precautions4,5. College and Hospital, Mayo Hospital, Services Hospital, Thousands of people infected with the life- Govt. Mozang Hospital, Jinnah Hospital, Lahore General threatening hepatitis C virus may have caught it during Hospital. Mian Munshi Hospital, Sheikh Zaid Hospital, routine dental treatment. Health campaigners warned that Railway Hospital, Wapda Hospital and CMH. Dental current practices in dental surgery, including the way surgeons who were not practically involved in dental tools are sterilized, may not be rigorous enough to procedures were excluded. remove the risk of transmission of the highly infectious Respondents were given ten minutes briefing on virus between patients. The transmission of HCV can the objectives of the study followed by a self filling of a occur via improper handling and cleaning of dental questionnaire containing study variables (socio- instruments. Risk of HCV transmission in this way has demographic characteristics, knowledge, attitude and proven by the researchers6 . practice of infection control procedures). There were 29 To minimize the risk of cross infection in the questions and 1 point was given for each correct answer dental clinic, specific recommendations have been issued and for all other responses, zero points were assigned. by professional health agencies. These recommendations Therefore, the score for knowledge ranged between zero include routine use of barrier techniques (gloves, masks), (no correct answers) and twenty nine (all answers correct). heat sterilization of dental instruments, vaccination against HBV, and the universal precautions7. Dentist’s Results compliance with these recommendations and infection control programs has been recently studied in different A total of 240 dentists were selected and out of 8-11 parts of the world . These studies indicate that there are whom 209(87%) agreed to participate in the study. Of gaps in some dentist’s knowledge regarding modes of 209 dentists 105 were from private sector and 104 from transmission of infectious diseases, the risk of infection public sector, majority (122) were males. Most of the from needle stick injuries, and awareness about general dentists (153=73.2%) were working as general measures which protect against HBV and HCV practitioners, 17 in operative dentistry, 11 in prosthetic 7 transmission . department, 8 in orthodontics, 2 in periodentics and18 in While it is important to assess health care diagnostic department. Hospital (public or private) was personnel’s hepatitis C knowledge, it is equally important the working place for 137(65.5%) dentists while to evaluate health care personnel’s attitudes and self- 72(34.4%) had their own clinics. The dentists of public reported behavior toward people with hepatitis C and to sector examined more than 30 patients a day as compared determine the factors that influence their behavior. to 15 patients in private sector. About 60% of public Interactions between patients and health care personnel sector and 40% of private sector dentitsts had less than represent an opportunity for education; yet if health care five years experience in their field. Almost a quarter personnel’s lack knowledge and hold judgmental dentists in public sector and 17% in private sector had no attitudes towards people with hepatitis C, they may not trained technician. 12 provide optimal treatment and care . Though most of the dentist had good knowledge Since dental health care workers may have about the causative organisms for hepatitis B and C and regular contact with hepatitis infected patients, they their mode of transmission but some deficiencies and should be aware of the dangers of the condition and the misconceptions were also seen. Some dentists from both necessary precautions that need to be taken. Our study public and private sector did not know about the targeted this group of dentists of public and private sector availability of HBV vaccine and some said that there is a in Lahore, as their knowledge, attitudes and practices are vaccine for HCV. Misconceptions about disease spread crucial in the management and control of Hepatitis B and through personal contact, mosquito bite and air and C viral infection. restriction of infected persons to work in food industry were also noted (Table-1). Subjects and Methods Almost all dentist (98.5%) agreed on screening of patients for hepatitis-B and C prior to any treatment. It was a descriptive cross-sectional study where The misconceptions noted were that giving last non-probability convenient sampling technique was used. appointment to the infected patient will prevent spread of Two hundred and forty dental practitioners (120 from infection and 52% dentists thought that the health public sector and 120 from private sector) were included professionals who are themselves positive should not be in the study. Dentists of the Private sector were taken discouraged from practice. from Shahdara, Badami Bagh, Mughalpura, Although over 95% dentists were inquiring Baghbanpura, Gulberg, Shadman, Mozang, Feroz pur about the past medical history from the patients but Road, Model Town, Multan Road, Johar Town and yet they were not taking adequate measures to protect Tohkher Niaz Baig. From public sector hospitals, dental

Pakistan Journal of Medical Research, 2012 (July - September) 94 Asia Batool, Misbah Ul Islam Khan Sherwani, Khatoon Akhtar Bano, Muhammad Aasim

Table 1: Knowledge of dentists about hepatitis B and C virus.

Knowledge of Dentists Private Sector Public sector p value (n=105) (n=104)

1. Update Knowledge 101 (96%) 100 (96%) 0.989 2. Hepatitis B & C caused by virus 104 (99%) 100 (96%) 0.169 3.. Hepatitis B & C can lead to cirrhosis/cancer 99(94%) 99(95%) 0.768 4.. Hepatitis B vaccine is not available 4(3.8%) 8(7.6%) 0.222 5. Interferon is not effective treatment for hepatitis-C 19(18.0%) 14(13.4%) 0.353 6. Unaware of that Hepatitis C virus has more than one genotypes 80(76%) 75(72%) 0.495 7. Vaccine is available for hepatitis-C 27(25.7%) 6(5.7%) 0.000 8. Hepatitis B & C spread by injecting equipment. 100 (95%) 98 (94%) 0.740 9. Hepatitis B & C spread through blood contact 104 (99%) 102(98%) 0.546 10. Hepatitis B & C spread through medical and dental procedure 98(93%) 96(92%) 0.769 11. Hepatitis B & C do not spread through sex 35(33.3%) 26(25%) 0.174 12. Hepatitis B & C spread through un-sterile tattooing. 93(88%) 96(92%) 0.347 13. Hepatitis B & C spread through blood transfusions. 104(99%) 100(96%) 0.152 14. Hepatitis B & C can not be transmitted perinately. 38(36.1%) 32(30.7%) 0.393 15. Hepatitis B & C positive person should not be restricted to work in food industry. 52(49.5%) 64(61.5%) 0.070 16. Hepatitis B & C can spread by personal contact 38(36.1%) 40 (38.4%) 0.726 17. Can spread through air in enclosed environment 97(92.3%) 95(91.3%) 0.777 18. Hepatitis B & C can spread through mosquitoes. 14 (13.3%) 16 (15.36%) 0.660

Table 2: Infection control measures practiced by dentists.

Infection control measures Private Sector Public sector p value (n=105) (n=104) 1. Enquire patient medical history 102 (97.14%) 100 (96.15%) 0.691 2. Were not vaccinated for hepatitis B 8 (7.6%) 12 (11.5%) 0.333 3. Were not wearing gloves 10 (9.5%) 10 (9.6%) 0.982 4. Do not wash hands with antiseptic soap/solution 7 (6.6%) 14 (13.4%) 0.097 5. Were not wearing masks/eye/face shield 26 (24.7%) 14 (13.4%) 0.034 6. Do not use new forceps/hand piecefor each patient 28 (26.6%) 14 (13.4%) 0.015 7. Do not use new saliva ejector for each patient 6 (5.7%) 6 (5.8%) 0.986 8. Do not use of autoclave for sterilization 6(5.7%) 11(10.5%) 0.052 9. Do not check working of autoclave 15(14.2%) 10(9.6%) 0.289 10.Do not disinfect impression casts/dentures/wax 47(44.7%) 39(37.5%) 0.275 11.Do not use of special container for disposal of sharps 25(23.8%) 29(27.9%) 0.490 themselves or their clients. This practice was more The knowledge about transmission of HBV and frequent in the private sector, where use of new HCV virus by blood and blood products in the present forceps/handpiece, mask and eye/ face shield, autoclave study were similar to those of another study16, however, for sterilization were significantly low (Table 2). misconceptions were noted with regard to infection transmission through sexual contact, mosquito bite and Discussion perinatal transmission and these were also under- recognised in other study17. Although sexual transmission Some important deficiencies were noted in the of HCV remains controversial, several studies have KAP about hepatitis B and C in both public and private reported independent associations between HCV sector dentists. In the present study the overall infection and exposure to an infected sex partner or physician’s response rate was 87% which is slightly increasing numbers of partners16. higher than that reported from Lahore (83.25%) on Lack of knowledge about interferon for the 13 infection control practices in dental practitioner . management of HCV was observed in the present study The mean knowledge score about the etiology and also from another study conducted in Rawalpindi18. and mode of transmission of HBV and HCV was higher In the present study 7% dentists were unaware of HBV in the present study when compared with the previous 14 vaccine which is of concern because almost all health one . However, other local studies reported a higher care providers especially doctors should be aware of the knowledge and awareness about risk of transmission of 15 HBV vaccine. In a study 99.2% medical and dental hepatitis virus in physicians of tertiary care hospitals . students at Dundee University were aware of Better information of physicians in tertiary care hospitals 19 immunization of HBV . The international guidelines on is probably due to their literature review and exposure to infection control state that standardize your disinfection various seminars and symposia. and sterilization practices and treat each case as if

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