Hepatitis B is a dreaded infectious disease and one of the major global public health
problems and is the tenth leading cause of death. The global disease burden is staggering
with about two billion people acutely infected and nearly 350 million chronically
infected with hepatitis B virus (HBV). Worldwide, it has been estimated that more
than 2 billion of the population has evidence of the past or recent HBV infection,
and there are more than 350 million chronic carriers of the mentioned infection. In
India, the prevalence of hepatitis B surface antigen (HBsAg) among the general population
ranges from 2% to 8%, placing India in an intermediate HBV endemicity zone. Our country
has over 50 million cases making it the second largest global pool of chronic HBV
infections. HBV is also the second most common cause for acute hepatitis in India
(after hepatitis E), being responsible for nearly one-third of acute viral hepatitis
patients. The seroprevalence is two to four times higher among healthcare workers.
This, in the context of an outsized population of the country and absence of a national
hepatitis B immunization program, could spell a projected escalating burden of the
disease in the years to come.
India has a much higher prevalence of HBV carriers than the developed countries, making
the Indian medical and dental students prone to exposure. One of the most serious
threats these students face during their clinical training is the possibility of exposure
to blood-borne pathogens, with the attendant risk of infection with HIV, HBV or hepatitis
C virus. Hepatitis B, among these, is the most important infectious occupational disease.
The high risk of being infected is the consequence of the high prevalence of virus
carriers in the assisted population, the high frequency of exposure to blood and other
body fluids and the high contagiousness of HBV. In fact, HBV infection is more dangerous
compared to HIV infection vis-a-vis occupational exposure is due to the fact that
its transmission rate after percutaneous exposure to blood is much higher (about 30%)
than that of HIV (0.3%).
A study from New Delhi in 1997 revealed that while only 2.3% preclinical students
were positive for HBsAg, and 18% and 10.4% for anti HBs and anti HBc respectively,
amongst the clinical group who had been exposed to the clinical departments, the corresponding
figures were 1.4%, 69% and 55% respectively. Another study from Mumbai in 2002 highlighted
the lack of awareness among medical and nursing students. Besides, the study also
revealed that only 26.3% of the medical students had taken 3 doses of hepatitis B
vaccination. However, a study from Orissa in 2000 found that although the vaccination
rate was 86.7% among dental students and 79.5% among medical students, it was an abysmal
1.9% among nursing students. None of the students received counseling about hepatitis
B vaccination at the time of admission to the medical college. Vaccination is the
best way by which one can armrest oneself against hepatitis B. Transmission rate is
as lofty as 30% in nonimmunized individuals, though it is a rare finding in those
who have been immunized.
An important facet of global HBV epidemiology is the emergence and increasing significance
of HBeAg negative infections as well as the distribution and significance of HBV mutants,
particularly those in the precore (PC) and basal core promoter regions of the HBV
genome. The prevalence of this “e” - negative chronic hepatitis B and its molecular
basis varies geographically. Thus, in the Mediterranean countries, nearly 90% of the
HBeAg-negative infections are associated with the PC mutants while this is 50% in
the Far East and 25% in the USA.
Ample data are available documenting that hepatitis B vaccination has been in vogue
for several years in other countries as well. In these countries, routine immunization
against hepatitis B has led to a significant reduction in the prevalence of chronic
HBV infection. The revelation of this effect in a wide array of countries and epidemiological
settings has established that this effect is independent of geographical and social
factors.
Based on this data, it is possible using mathematical modeling techniques to reckon
the likely effects of a universal neonatal immunization program on the health status
and survival of the Indian population. Attention should be paid to find out if the
young medical and dental students possess correct knowledge about the disease, its
risk factors, modes of transmission and consequences and do not harbor any misconceptions
about it. A strong hold of such basic knowledge would go a long way in helping them
to protect them.
From the information available at hand, it is now quite evident that although the
western institutions have taken passable steps to protect and fight against the disease,
despite the minimal risk, the Indian institutions including the statutory bodies like
the Indian Medical Council, Dental Council of India, the University Grants Commission,
and the Ministry of Health, and professional bodies like the Indian Medical Association,
Indian Society of Gastroenterology, Indian National Association for Study of the Liver
and the Association of Physicians of India pretend to be ecstatically ignorant of
their contractual obligations and odd jobs in this regard.
The young and inexperienced medical and dental students might underestimate the risk
of exposure. Even if not performing invasive procedures, chance of mucocutaneous exposure
while examining the patients physically still exists, so do that of accidental exposures
due to improper disposal of sharps. This reduced perception of risk may translate
into recklessness which can prove hazardous. Compliance with universal precautions
has been found to be lower among health care workers with a lower perception of risk.
In the practically scenario, exposure cannot be avoided, therefore, it should be ensured
that the students know the standard postexposure prophylaxis protocol in case any
accidental exposure. They ought to be made to comprehend the extreme importance of
immediately reporting the incident to the concerned authorities, undergoing prompt
investigations and seeking appropriate treatment and suitable follow-up. This is of
prime importance owing to the time constraints for the administration of hepatitis
B immune globulin to persons who have inadequate HBV antibody protection. Finally,
an attempt should be made to identify factors which persuade the awareness level and
vaccination status of students. Interventions, to improve and maintain optimal compliance
with infection control guidelines, are required and must take into consideration personal
factors as well as organizational and administrative factors.
India is on the doorsteps of espousing an HBV prevention program. Based on the global
experience, it is liable that an effective childhood immunization program will reduce
the burden of infection in this country. Formulation of a national policy is of utmost
importance. While the medical and dental students ought to be protected, measures
are called for the patients from being unwittingly infected from an infectious health
care provider. An aggressive approach needs to be followed as regards to vaccination
and steps should be taken to provide for adequate reparation.