Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt

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Infection, Disease & Health xxx (xxxx) xxx

Available online at www.sciencedirect.com

ScienceDirect journal homepage: http://www.journals.elsevier.com/infectiondisease-and-health/

Research paper

Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt Rehab H. El-Sokkary a,*,1, Rehab M. ElSaid Tash a,1, Eman M. Mortada b,c,2, Omnia S. El Seifi b,2 a

Medical Microbiology & Immunology Department, Faculty of Medicine, Zagazig University, Egypt Community, Environmental and Occupational Medicine Department, Faculty of Medicine, Zagazig University, Egypt c Health Sciences Department, Health Sciences & Rehabilitation College, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia b

Received 20 July 2019; received in revised form 27 July 2019; accepted 17 October 2019

KEYWORDS HBV vaccine; Anti-HBs; Infection control; Non-responder; Middle-income countries; Occult HBV

Abstract Background: Hepatitis B virus (HBV) infection is the most common serious liver infection. The study aimed to evaluate the effect of a HBV protection intervention on interns, as regards their knowledge, attitude and immune response to HB vaccine and to identify the factors affecting their compliance and immune response to HB vaccination at Zagazig University Hospitals. Methods: A quasi-experimental study was conducted in 3 phases over 10 months. Phase 1: assessment of knowledge, attitude and HCV/HBV immune status. Phase 2: the implementation of HBV protection campaign; vaccine administration and health education sessions. Phase 3: the assessment of the immune response to the vaccine and the change in knowledge and attitude. Results: Out of 120 participants, 60% were compliant to the vaccination schedule. Needle-stick injury, the seriousness of HBV infection and attendance of infection control courses are the motivating factors to vaccination (p < 0.05). After the 3rd dose, 9.7% were non-responders. BMI and diabetes were the statistically significant predictors of the immune response. The HCWs compliant with vaccination schedule had higher mean scores regarding; total knowledge (15.5  2.1), p < 0.0001 and attitude (14.34  3.8) p < 0.05. A significant improvement is recorded from the posttest results, p < 0.000. Conclusions: A comprehensive protective program against HBV is an effective tool. A compulsory vaccination program is still needed for interns. Post vaccination monitoring program, including protective measures for vaccine non responders is urgently needed with strict follow

* Corresponding author. 12 Abdaziz Ali street, Zagazig, Egypt. E-mail address: [email protected] (R.H. El-Sokkary). 1 These authors contributed equally to this work. 2 These authors also contributed equally to this work. https://doi.org/10.1016/j.idh.2019.10.002 2468-0451/ª 2019 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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R.H. El-Sokkary et al. up of at risk groups. Occult HBV cases should not be overlooked when screening for immune response to vaccine. ª 2019 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.

Highlights  Compulsory HBV vaccination and post-vaccination monitoring programs for interns are highly recommended.  Risk Exposure, seriousness of HBV infection and control training are significant motivators for vaccine compliance.  Needle stick injury, family history of HBV and level of knowledge about HBV infection and vaccination are significant predictors of HBV infection.  Awareness about vaccine non responder status should be disseminated among interns, including protection and risk factors.  Occult HBV should be considered as one of the causes for non-responder status among interns.

Introduction Hepatitis B virus (HBV) infection is the most common serious liver infection [1]. Frequent exposure of Egyptian healthcare workers (HCWs) to HBV infection is significantly high [2]. This high predisposition is mainly due to needle stick injuries and accidental exposure to infected blood and other body fluids [3]. In the absence of proper preventive measures, infected HCWs could be an eminent source for HBV infection transmission to their patients [4]. A prevalence rate of 1.5% was recorded among Egyptian HCWs [5]. Moreover, a significant number of HCWs have an occult hepatitis B infection [6]. Compliance with standard precautions and routine preexposure hepatitis B vaccination are the most costeffective methods to prevent HBV infection [7]. HBV vaccination rates among HCWs in the Middle East and low socioeconomic countries have been reported to be unsatisfactory [8]. In Egypt, HBV vaccination coverage remains low [9]. In this context, the level of awareness, perceived risk, as well as the role of attitude, should not be overlooked [10]. The post-vaccination hepatitis B surface antibody testing should be carried out 1e2 months after the final dose of the primary course of vaccination [11]. Several factors may affect the immune response [12]. For this reason, a post-vaccine quantitative test for anti-HBs is usually recommended, especially for high-risk groups like health care workers [13]. In Egypt, there is limited data about the rates of post-vaccination seroconversion among HCWs who received recombinant HBV vaccination [2]. No obligatory test is routinely done after vaccine completion to identify and measure anti-HBs production. At the start of their medical career, the interns could be at high risk of catching HBV infection. Although different studies were conducted to assess the vaccination effectiveness among HCWs, yet no study has been conducted about HBV protective interventions among the newly graduated Egyptian physicians (Interns). Thus, this study was designed

to target this specific group of HCWs. The study has the following objectives: To evaluate the effect of a HBV protection intervention on interns, as regards their knowledge, attitude and immune response to HB vaccine and to identify the factors affecting their compliance and immune response to HB vaccination at Zagazig University Hospitals.

Methods Study setting Zagazig University Hospitals are located in the eastern region of Egypt. It provides medical services for many governorates in the Delta and Sinai regions. Every year, it receives a group of newly graduated medical students to work for one year as interns. In May 2016, the researchers, as representatives of the infection control team at Medical microbiology and immunology department, announced for a HBV protection campaign. It targeted the most recent batch of interns. The campaign aims to provide awareness and protection against the HBV infection. It included a health education program and vaccine administration. The total number of interns at the time of the study was 1100, from which 365 responded and were willing to participate in the campaign representing (33.18%).

Study design, subjects and sampling This quasi-experimental study was conducted in 3 phases over 10 months. Phase 1 “preparatory phase”: It included an assessment of knowledge and attitude as well as HCV and HBV immune status. It was carried out in June 2016. Phase 2 “intervention phase”: It included the implementation of the HBV protection campaign; vaccine administration and health education program. It extended from July 2016 to February 2017. Phase 3 “assessment phase”: It included the assessment of immune response to the vaccine and the evaluation of knowledge and attitude.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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Hepatitis B vaccine among Egyptian interns This took place in March 2017. Laboratory investigations were carried out at medical microbiology and immunology department Zagazig University.

Sample size calculations It was calculated via epi info 7 programs using the following input data: the mean score attitude in pretest was 17.2  1.2, and the mean score for attitude in posttest was 18.1  2.8 from a pilot study, confidence interval equals 95% and power of test 80% and a 10% nonresponse rate. The final sample size was 198 interns. They were selected by simple random sampling technique from a numbered list of the campaign respondents (365) through the SPSS program. The selected interns were invited to participate in the study and offered the study proposal. Inclusion criteria involved: agreed to participate in the study, susceptible persons to HBV; no past or current infection of HBV or previous HBV vaccination. Exclusion criteria included those who had past or a current HCV infection or are on steroids/immunosuppressive therapy.

Outcome measures The primary outcome is the vaccine compliance rate, change in knowledge and attitude and the immune response to the vaccine. Secondary outcomes are the factors motivating the participated physicians to be complete the 3 shots with HB vaccine and their immune response predicting factors.

Phase I: (preparatory phase) Serological testing Interns underwent serological testing to assess the antibody status of each participant before enrollment in the study. It checked for current or past HBV infection or vaccination and HCV current or past infection. Blood sampling. For each participant, 5e10 ml venous blood was collected under complete aseptic conditions and were allowed to clot at room temperature (18 e20  C). Samples were then centrifuged at 10,000 rpm for 10 min. The separated sera were divided into aliquots and stored at 20  C until further testing. Testing for HCV. This was done to exclude HCV infection. Detection of anti-HCV Ab was done by a commercially available 3rd generation enzyme immunoassay (Hepanosticka HCV Ultra; UBI Diagnostics, Beijing, China). Equivocal results were further tested by real-time PCR for confirmation [14]. Participants with current or past HCV infectionwere excluded. Testing for HBV. Different serologic “markers” or combinations of markers were used to identify different phases of HBV infection and to determine whether a participant has acute or chronic HBV infection, is immune to HBV as a result of prior infection or vaccination or is susceptible to

3 infection. The HBV markers were detected by standard enzyme immunosorbent assay (ELISA) using commercial kits for anti-HBc IgG, anti-HBs, HBsAg and anti-HBc IgM according to manufacturers’ instructions. Firstly, anti-HBs was tested for in all serum samples (To exclude naturally infected or vaccinated). Secondly, antiHBc IgG was tested for those who were reactive to anti-HBs (to differentiate between natural infection or vaccination). Thirdly, HBsAg was tested for the remaining serum specimens that were not reactive to anti-HBs. The Interpretation was done as follows: Susceptible: tested negative for HBsAg, anti-HBc and anti-HBs. Immune due to natural infection: tested negative for HBsAg and tested positive for anti-HBc and anti-HBs. Immune due to hepatitis B vaccination: tested negative for HBsAg and antiHBc and tested positive for anti-HBs. Acute infection: tested positive for HBsAg, anti-HBc and IgM anti-HBc and tested negative for anti-HBs. Chronic infection: tested positive for HBsAg and anti-HBc and tested negative for IgM anti-HBc and anti-HBs [15]. Positively reacting sera for HBsAg were excluded as having currently HBV disease. For cases with negative HBsAg, investigation for HBV DNA was performed as described earlier [2]. Participants with positive DNA testing were excluded “seronegative occult HBV infection”. Assessment of knowledge and attitude Eligible interns (120 interns) who met the inclusion criteria were assessed for their knowledge, attitude and motivating factors regarding HBV infection and vaccination through a pretest questionnaire. Questionnaire. A self-administered structured questionnaire was designed with some modification, according to a previously published study [16]. The questionnaire was divided into four parts, the first one assessed the general characters of the participants as; age, gender, residency, marital status, weight, height,“ were measured by weight and height scale”, family history of HB and/or HCV infection, history of previous needle stick injury, smoking, associated comorbidities. The second part of the questionnaire was designed to explore the motivating factors for physicians to be vaccinated by HBV vaccine, e.g., the seriousness of the disease, higher risk of exposure to infection at work, to protect family and patients, the effectiveness of the vaccine, previous attendance of infection control orientation sessions. The response was either yes “score 1” or no “score 0”. The third part of the questionnaire included 11 positive statements to assess physicians’ knowledge about HBV modes of transmission, risk factors, complications and 13 positive statements about HB vaccine schedule, indications contraindications, prophylactic value, safety and factors affecting the immune response. The answers to these questions were either; true “score of 1”, false or I don’t know “score of 0”, this gives a range of knowledge score from (0e11) for HBV modes of transmission, and (0e13) for HBV vaccine and immunity, resulting in a total knowledge score ranging from (0e24). The fourth part consists of 15 statements prepared to assess the attitude of the participated physicians about HB

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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4 vaccination and the infection control measures to prevent transmission of HBV. The statements were answered and scored according to a modified 3 points Likert scale as (agree “2”, neutral “1”, disagree“0”), giving total attitude score ranging from (0e30). The questionnaire was reviewed by experts, and the reliability was tested, where Cronbach’s alpha was 0.75. A Pilot study was carried out before the study on 10 interns who weren’t included in the study, modifications, and language review was conducted accordingly.

Phase II (intervention phase) It encompassed of the delivery of a health education sessions and administration of HBV vaccine. Health education The objectives of the health education session were to increase knowledge and improve the attitude of the participated interns about; about the epidemiology of HBV, mode of transmission, prevention and infection control measures. It also focuses on HBV vaccine, doses, and risk factors that may interfere with the full immune response. The education message was formulated based on CDC guidelines and recommendations [13]. Each 10e15 interns were grouped, and a health education message was delivered to them over 40 min, through interactive sessions between the researchers and the participants by questions, discussion, case study and role-play and demonstration by power point presentation. This helped the attendants to be more engaged and to express their concerns regarding the clinical practice and infection control measures. At the end of the health education session, a summary of the main important information was presented at the using power point presentation. Educational materials in the form of colored brochures were used, including the main key points regarding infection control measures and prevention methods were distributed to the participants. Vaccine administration It was performed under complete aseptic conditions and following safe injection precautions. Three shots of recombinant HBV vaccine (Engerix B e Glaxo SmithKline Biological) were administered intramuscularly over the deltoid region. An adult dose of 20 mcg of hepatitis B surface antigen per ml was applied. Vaccination was done according to the Centers for Disease Control and Prevention (CDC) schedule (0, 1 and 6).

Phase III: (assessment phase) During this phase, the immune response to HBV vaccine was evaluated; this was applied after completion of the 3 vaccination shots. A post-test questionnaire was distributed to the participated interns to reassess their knowledge and attitude. The serological response to the vaccine was evaluated by quantitative assay of anti-HBs (AccuDiag-HBsAb Quantitative ELISA Diagnostic Automation/Cortez Diagnostics, Inc USA). All tests were done according to the manufacturers’ instructions. Accordingly, participants were divided into

R.H. El-Sokkary et al. Non-responders with anti-HBsAb level <10 IU/L, Responders; anti - HBsAb level of 10 IU/L.

Statistical analysis The data collected was analyzed using the Statistical Package for Social Sciences Program (IBM SPSS Statistics, Version 19). Body mass index (BMI) was calculated according to the following formula; weight in kg/height in meter squared, and according to the results the physicians were classified as underweight if less than 18.5, normal weight if the result between “18.5e24.9”, overweight if it is from “25e29.9” and obese if “more than or equal 30”. Simple descriptive statistics were used (mean  standard deviation for quantitative variables and frequency with percentage distribution for categorical variables). A t-test and paired ttest were used to measure the differences in mean knowledge and attitude practice scores about HBV infection, vaccination, and immunity among the studied groups. Chi-square and Fisher exact test were computed to find the association between qualitative variables under study. Logistic regression was used to find the factors that can predict the completion of the vaccination schedule and the immune response among the participated physicians. The P-value  0.05 was used as the cut-off level for statistical significance.

Results Study participant characteristics Out of them 365 interns attending the vaccination campaign, 198 were selected, 23 refused to participate, 24 were excluded by history taking. The remaining 151 interns passed through the different phases of the study. Eleven subjects were excluded due to past or current HCV; a prevalence of HCV infection (7.3%). Sixteen had HBV infection; a prevalence of (10.6%). The latter included 3 cases with occult HBV infection; a prevalence of (1.99%). Four physicians were excluded due to previous HBV vaccination. A total of 120 participants were enrolled in the current study (Fig. 1). The participated interns’ characteristics are presented in (Table 1). They were mostly aged 25.8 years old, males 50.8%, from urban areas 55.8%, single 95.0%, didn’t have a family history for HBV and/HCV infection (85.0%), nor needle stick injury 89.2%, nonsmokers 73.3%, most of them were having normal BMI 68.3% and absence of comorbidities 81.7%. Out of the 120 participants, seventy two participants had completed the 3 doses of vaccine, with a 60% compliance rate. Accordingly, the participants were divided into two groups, where 72 of them have received the full dose of the vaccine, opposite to 48 of them who haven’t. The factors that motivate the participated physicians to undergo vaccination with HBV vaccine were demonstrated in Fig. 2; The vaccinated physicians who completed the 3 doses of vaccine were significantly motivated mostly due to, the exposure to risk factors at work, the seriousness of HBV infection and attendance of infection control courses (p  0.05).

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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Hepatitis B vaccine among Egyptian interns

5 Table 4 shows that there were factors significantly associated with the non-responder status of the interns after the 3rd dose of the vaccine. This included obesity and overweight, diabetes and rheumatic diseases, p < 0.05. Timing of test performance is another important factor; examining the immune response in a period of time from 1 to 2 months from the 3rd dose of vaccine was significantly associated with positive immune response more than examining after 2 months, p < 0.05; 38 physicians were assessed within 1e2 months after completing the 3rd dose of the vaccine, 34 physicians were assessed after 2 months. Regression analysis revealed that BMI and Diabetes were the significant factors that can predict the immune response among the participated interns (Table 5). Fig. 4 demonstrates that the mean knowledge score of the interns who completed the full dose of vaccination about HBV infection and vaccination, their total knowledge and total attitude significantly increase in the post-test, p < 0.000.

The questionnaire results showed that the physicians who completed the 3 doses of vaccine had significantly higher mean scores than those who didn’t complete the vaccine shots with the p  0.05. Table 2 This was the same to HBV modes of transmission, which was (9.4  1.3), HBV vaccine and immunity (7.12  0.8), total knowledge about HBV infection and vaccine (15.5  2.1), and attitude (14.34  3.8). Fig. 3 Demonstrate the vaccine immune response for the 72 participants who completed the 3 vaccination shots. The non-responders represented (9.7%) with mean anti-HBs Abs was (0.4  0.0 IU/L). The responders were representing (90.3%) and mean anti-HBs Abs was (246.24  89.6 IU/L). Table 3 showed that exposure to needle stick injury, family history of HBV as well as the level of knowledge about HBV infection and vaccination were the significant factors that can predict the completion of the vaccination schedule among the studied physicians.

365 interns joined the vaccina on campaign

198 were selected

23 refused to par cipate

24 were excluded by history taking

31 were excluded by serological inves ga ons -11 (7.3%) HCV past infecƟon -16 (10.6%) HBV past or current infecƟon - 4 HBV previous vaccinaƟon

120 were enrolled for the study

72 completed the administrtaion of

3 vaccine shots

48 Did not complete the administrtaion of 3 vaccine shots

- Assess the immune respone to vaccine - parƟcipate in the quesƟonnaire

- parƟcipate in the quesƟonnaire only

38 case tested for the immune response within 1-2 months from 3rd dose )

34 cases tested for the immune response aŌer 2 months from 3rd dose )

Figure 1

Recruitment process of study participants.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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R.H. El-Sokkary et al. Table 1 General physicians.

characters

Variables

of

the

No. (120)

% (100.0)

Age Mean age  (SD) years 25.8  1.66 Gender Male 61 Female 59 Residence Urban 67 Rural 53 Marital status Single 114 Married 6 Family history of HBV and/HCV No 102 Yes 18 History of needle stick injury No 107 Yes 13 Smoking No 88 Yes 32 BMI Normal weight (18.5e24.9) 82 Overweight (25e29.9) 26 Obese (30) 12 Comorbidities: No morbidities 98 CVDs 8 Diabetes 7 Rheumatic diseases 3 Respiratory diseases 4 Vaccination status for HB vaccine Incomplete 48 Complete 72

50.8 49.2 55.8 44.2 95.0 5.0 85 15.0

Variables

Incomplete administration of 3 vaccine doses

Complete administration of 3 vaccine doses

P

Knowledge about HBV modes of transmission Knowledge about HBV vaccine and immunity Total knowledge Total attitude

8.1  1.4

9.4  1.3

0.000*

5.80  1.7

7.12  0.8

0.000*

13.9  2.6 14.34  3.8

15.5  2.1 15.64  2.4

0.000* 0.023*

*p  0.05 is significant. t test was computed.

89.2 10.8

9.7

73.3 26.7

non-responders responders

68.3 21.7 10.0

90.3

Figure 3 State of immunity of the participated physicians after complete administration of 3 vaccine doses.

81.7 6.7 5.8 2.5 3.3

Discussion About, 24% of the health workforce worldwide remains unvaccinated against HBV [17]. Compliance to the vaccine (Complete the 3 vaccination shots) is still unsatisfactory [18]. This was observed in the present study, where only

40.0 60.0

93.8

100 90

Table 2 Comparing the mean knowledge and attitude scores about hepatitis B vaccination and infection among the interns according to their compliance with vaccination.

participated

80.6

80.5 75

80

68.1

70

62.5

64.4

62.5

61.1 55.6

60

54.2

50

40.3

Incomplete vaccine doses

40 30 20 10 0 exposure to risk of neddle s ck injury

prevent infec on to pa ents

protec on of family members

HBV seriousness

effrec vness of the vaccine

a ending infec on control courses

Complete 3 vaccine doses

Chi-square was computed, P <0.05 for exposure to risk to needle stick injury, seriousness of HBV and attending infection control courses

Figure 2

Factors motivate the participated physicians to be vaccinated with HB vaccine.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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Hepatitis B vaccine among Egyptian interns

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Table 3 Regression analysis of factors significantly predicting the completion of the immunization schedule among the studied physicians. Items

B

S.E.

p value

OR

95.0% C.I. for OR Lower

Upper

Exposure to needle stick injury Family history of HBV infection Knowledge about HBV infection and vaccination

1.246 1.211 1.611

0.539 0.630 0.680

0.019* 0.043* 0.018*

0.282 0.298 5.010

0.098 0.087 1.321

0.812 1.024 19.000

*p  0.05 is significant.

60% of the enrolled subjects have completed their vaccination course. Previous study reports were variable for HCWs; 100% in Poland [19], 57.1% in India [20], 63.3% in Saudi Arabia [21], 85.6% in Pakistan [22], and only 19.9% in South Africa [23]. Studies from Egypt, Brazil and Nigeria indicated that only 16e60% of HCWs had received complete HBV immunization [24]. Despite the availability of an effective vaccine in the market, doctors continue to remain non-vaccinated [22]. The perception of the occupational risk of infection was assumed to be an important public health issue that influences vaccinations [25]. This is confirmed in the present research; the physicians who completed the administration of 3 vaccine doses showed significant risk perception to exposure of infection at work, the seriousness of the HBV infection. Moreover, their attendance for infection control sessions about HBV infection is a statistically significant

motivating factor for protection by vaccination. There is a need for strict health policy to ensure that the doctors get a complete vaccination before they start their professional training [22]. Identifying such driving forces could be used in motivating the physicians to get the vaccine. Subsequently, it could help in improving vaccination coverage. Knowledge and perception of risk represented in previous exposure to needle stick injury and presence of family history of HBV and/HCV infection were the most significant factors predicting the completion of the 3 doses of the vaccine. This agrees with the results of other studies conducted in Nigeria and Serbia [24,26]. In order to achieve sound practice regarding vaccination and infection control measures, an official annual protection program should be established in the university hospital directed for the new patch of interns. The mentioned factors could be used in articulating the awareness messages.

Table 4 Factors associated with the immune responses to HB vaccine among the interns who complete full dose of vaccination (n Z 72). Factors

Categories

No. 72

Non responders <10 IU/L (No. 7)

Responders 10 IU/L (No. 65)

P

Age

25 years >25 years Male Female Urban Rural Single Married Negative Positive Negative Positive Non smoker smoker Normal weight (18.5e24.9) Over weight (25e29.9) Obese (30) No Yes No Yes No Yes 1e2 months >2 months

62 10 30 42 36 36 69 3 62 10 64 8 49 23 40 21 11 68 4 67 5 70 2 38 34

6 1 5 2 5 2 6 1 5 2 6 1 6 1 0 1 6 6 1 3 4 5 2 1 6

56 (86.2) 9 (14.8) 25 (38.5) 40 (61.5) 31 (47.7) 34 (52.3) 63 (96.9) 2 (3.1) 57 (87.7) 8 (12.3) 58 (89.2) 7 (10.8) 43 (66.2) 22 (33.8) 40 (61.5) 20 (30.8) 5 (7.7) 62 (95.4) 3 (4.6) 64 (98.5) 1 (1.5) 65 (100.0) 0 (0.0) 37 (56.9) 28 (43.1)

0.999

Gender Residence Marital status Family history of HBV Exposure to needle stick injury Smoking BMI

CVD Diabetes Rheumatologic diseases Time of immune response testing

(85.7) (14.3) (71.4) (28.6) (71.4) (28.6) (85.7) (14.3) (71.4) (28.6) (85.7) (14.3) (85.7) (14.3) (0.0) (14.3) (85.7) (85.7) (14.3) (42.9) (57.1) (71.4) (28.6) (14.3) (85.7)

0.120 0.429 0.268 0.249 0.578 0.418 0.000*

0.342 0.000* 0.008* 0.047*

Time of immune response testing: is the duration between 3rd dose of HB vaccination and immune response testing. Fisher exact was computed *p  0.05 is significant.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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R.H. El-Sokkary et al. Table 5 Factors significantly predicting the immune response among physicians who complete the full dose of vaccination. Items

B

S.E.

p value OR

BMI 2.778 1.080 0.010* Diabetes 4.447 1.264 0.009*

95.0% C.I. for OR Lower

Upper

0.062 0.007 0.012 0.001

0.561 0.140

*p  0.05 is significant.

In the current study, about 90.3% of the participated physicians get immunity after completing the 3 doses of the vaccine. We reported a 9.7% non-responder rate. Previously published reports showed the percentage of healthcare professionals who remain unprotected after 3 doses of vaccine, ranged from 10% [17] to 20.9% [27]. In two studies from Egypt and Sri Lanka, the non-responder rate of the hepatitis B vaccine was 9% [16] and 9.9% [28], respectively. The differences in the non-responder rates between the different studies may be due to differences in the characteristics of each study group, e.g., ethnicity, the prevalence of hepatitis infection, or prevalence of chronic diseases [15]. It is noteworthy that occult HBV infection is one of the important causes of the non-responder status [2,29]. In the current study, 3 interns were excluded from the beginning due to having an occult HBV. Many factors were significantly associated and could predict the immune response to HB vaccine. In agreement with previous studies, obesity and diabetes were significant predictors for immune non-response to HB vaccine in the present study [30]. This could be explained as increasing adipose tissue in obese person as well as the hormonal effect associated with obesity and diabetes may have a role in decreasing the antibody titer and increasing the nonresponse rate [31,32]. Although age could affect the rate of nonresponse to the HBV vaccine [33], however, it couldn’t apply here as all participants are within the same

age group. This could help in the preparation of postvaccination monitoring programs with strict follow up of at-risk groups. As per published guidelines [13], the researchers of the present study offered the vaccine nonresponders with the appropriate preventive measures that suit their immune status. It is highly recommended that the post-vaccination testing for antibodies must be 1e2 months after the last dose of the vaccine, the time from the 3rd dose of the vaccine till examining the immune response is an important factor affecting the seroconversion [11]. Our results demonstrate that examining the immune response in a period from 1 to 2 months from the 3rd dose of vaccine was significantly associated with a positive immune response more than examining the immune response after 2 months. Strict measures should be followed to encourage vaccinated physicians for post-vaccination antibody testing at the proper time. Knowledge and attitudes of the health care providers represent the corner stone toward their practice to prevent HBV infection. This was demonstrated in our results where the completely vaccinated physicians had significantly adequate knowledge about HBV modes of transmission, vaccine and immunity in addition to their positive attitude more than those with incomplete vaccination. This agreed with the findings of a previous study conducted in Cameron [34]. The knowledge and attitude of the participants significantly increased after the application of a health education program, which is similar to the result of other similar study conducted in India [35]. In our opinion, this result was important as it creates a state of awareness among the participated interns who are at risk of exposure to HBV infection and hopefully this will lead to improving their behaviours regarding infection control measures. This again puts us in front of the importance of having a formal education program for the interns before they start their practical work based on the fact that the good knowledge will be translated into positive attitude, which will be reflected on the adequate practice that leads to

18.7

20 15.5

17.4 15.64

15 9.4

10.2

10

8.5 7.12

pretest

5 0 Knowledge about HBV modes of transmission

Knowledge about HBV vaccine and immunity

Paired t test was computed, p<0.000 for all variables.

Total knowledge

Total aƫtude

post-test

p ≤ 0.05 is significant.

Figure 4 Changes in the mean score of knowledge and attitude from the pre to posttest among interns who complete the vaccination schedule.

Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002

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Hepatitis B vaccine among Egyptian interns protection against infectious diseases and this is the ultimate goal of the health care system.

Conclusions The sixty percent of the interns have completed a full dose of HBV vaccine. They were motivated by exposure to needle stick injury, the seriousness of HBV infection and attendance of infection control courses. Among them, 9.7% were vaccine non-responders. BMI and diabetes were the statistically significant predictors of the immune response. The health education intervention improves knowledge and attitude of the participants from the pre to posttest. A compulsory vaccination program is still needed, an official annual awareness program should be stablished in the university hospital directed for the new patch of interns. Preparation of post vaccination monitoring programs is needed with strict follow up of at risk groups. Occult HBV cases should not be overlooked when screening for immune response to vaccine. Protective measures of vaccine non responders should be disseminated. Larger scale studies with more stratification of HCWs are highly recommended.

Ethics The study protocol was approved by the IRB e Faculty of medicine- Zagazig University No 4890 it has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The participants were informed about the study objectives, and that they can withdraw at any time with protecting the privacy of research participants, informed written consent was obtained from all the participants.

Authorship statement All listed authors certify they participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the, manuscript.

Conflict of interest No conflict of interest was present.

Funding No external funding support was received.

Provenance and peer review Not commissioned; externally peer reviewed.

Limitations of the study The study was conducted in a single University hospital. However, it is the only hospital that receives most of the newly graduated physicians every year. A difficulty was

9 faced in conducting randomization for the interns included in the study. This occurred due to the different working hours and shifts in each hospital department. However, the results represent an alarming sign which should be considered by the healthcare authorities elsewhere to improve vaccine compliance.

Acknowledgement The authors dedicated their sincere appreciation to the participating physicians for their cooperation and contribution.

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Please cite this article as: El-Sokkary RH et al., Evaluation of a hepatitis B virus protection intervention among interns at Zagazig University Hospitals, Egypt, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2019.10.002