Hepatitis B vaccine coverage among primary healthcare workers

Abstract
Background: The Hepatitis-B virus (HBV) causes a most severe, deadly liver disease that goes by the same name. Its vaccine has, since 1982, proven remarkably successful in terms of effectiveness and safety, thereby ensuring its administration to every healthcare worker (HCW), for safeguarding them against occupational exposure.
Objective: To deduce HBV-immunization coverage extent, views and knowledge regarding it, and obstacles to proper immunization of primary HCWs.
Method: This descriptive, cross-sectional research employed a self-administered questionnaire, which was handed out to PHCWs in four primary healthcare divisions affiliated to Al-Madinah Al-Munawwarah’s Directorate General of Health Affairs.
Results: The study randomly chose 645 PHCWs; 542 completed questionnaires were handed in, thus making the total response rate 84%. Outcomes indicated that 73.8% PHCWs were fully vaccinated, 15.9% partially vaccinated, and 10.3% never received vaccination.
Conclusions:  Primary preventive strategies, like universal precaution and immunization, for safeguarding PHCWs from HBV, must be implemented.

1.1 Background
    The Hepatitis B virus (HBV) causes an acute, deadly liver disease, and constitutes a crucial global health issue. HBV initiates chronic liver problems, resulting in death from liver cancer and cirrhosis.1-2-3Around 2 billion individuals worldwide are estimated to be HBV-infected; over 350 million develop chronic liver diseases.1The backbone of HBV-protection comes from its vaccine– the most effective HBV-curbing intervention. The World Health Organization (WHO), in 1991, recommended it to all nations; by 2009, 177 nations reported all babies receiving the vaccine. Worldwide estimated HBV-vaccine coverage was around 69% in 2008.4-5Nearly 0.5-1.2 million individuals succumb to HBV-complications per annum.6-7    
    HBV vaccine has, since 1982, proven remarkably successful in terms of effectiveness and safety; over a billion HBV-vaccines have globally been administered. Immunization has decreased chronic infection in several nations, wherein 8-15% kids would contract chronic HBV-triggered infection. This first-ever vaccine for a major form of cancer offers lifelong (minimum 20-years’) protection.8 Drop in HBV-infection occurrence and associated morbidity/mortality rates owing to the vaccine led the Centers for Disease Control and Prevention (CDC) to mandate HBV-inoculation for all HCWs in 1997.9Still, there is poor compliance in numerous healthcare settings, particularly in developing nations; Saudi Arabia’s HCW-immunization status is yet unclear. The country presents no recent HCW HBV-vaccine coverage study; only one prior research exists, portraying 39% coverage.10
          HCWs are directly exposed to infected patients (blood pathogens /body fluids) in healthcare facilities and labs.11 HB-infection constitutes an occupational hazard, chiefly transmitted via contaminated body fluids/blood. Global HBV burden projected 66000 HB-cases and 261 annual HCW deaths due solely to infected sharp-objects. Barely 40-60% developing nations’ HCWs become HBV-infected because of percutaneous sharp-object-inflicted occupational exposure.12Since 1981, HB has become preventable because of its efficient, immunogenic vaccine.13
The WHO’s mean estimates of HBV-immunization among developing nations’ HCWs was 19-39% as opposed to developed nations’ 67-79% estimate.12Chiefly, the program has been successful, ensuring HCWs’ immunity against all preventable illnesses. High HCW HBV-immunity rates helps decrease disease transmission. It is easier to prevent and reduce HBV-connected occupational hazards via immunization programs for HCWs than to manage and control disease outbreak.14Saudi Arabian vaccination recommendations are identical to CDC recommendations,15 i.e., HB-vaccine administration in 3 doses, with second and third doses administered 1 & 6 months after first dose to at-risk HCWs. Most Saudi Arabian researches on HBV-vaccination involve dentists, other specific healthcare segment’ specialists, 16 or special, Hajj-season HCWs.17 There is no research as yet regarding Saudi Arabian PHCWs’ hepatitis B vaccination coverage.
1.2. Study Significance
Study outcomes will aid national occupational health and infection control policies for Saudi HCWs. HCW-immunization (thereby disease-prevention) is much more economical than treatment/management after contracting HBV-infection. Outcomes will ascertain infection control and assess immunization program efficacy.
1.3 LITERATURE REVIEW
1.3.1 HB Epidemiology 
Causative agent
HBV causes hepatitis (liver inflammation) which may cause other infections like asymptomatic infection, and chronic/acute infection (resulting in hepatocellular carcinoma and liver cirrhosis.)18
1.3.1.1 Transmission
HBV-transmission occurs by contact with infected body fluids (blood, saliva, semen.)19 Unprotected sex20, contaminated syringes/needles21, percutaneous and parenteral exposure (acupuncture, tattooing, household contact, transfusions and dialysis25) and infant-exposure via mother23-24 are major transmission modes. HCWs have greatest HBV risk.22 
Patient-to-HCW-transmission: 
HBV-impregnated needles are the leading HBV-transmission mode among HCWs. Average inoculated-blood volume via needle-pricks decides HBV-transmission risk. Research of HCWs exposed to HBV in this manner showed 6-14% contracting the disease and 27-45% developing serologic HBV-infection evidence.26 
1.3.1.2 HBV Prevalence 
HBV distribution can be segregated in 3 levels (low-intermediate-high) depending on disease endemicity. Developing areas, like China, Africa’s sub-Sahara, Amazon Basin and South-East Asia are highly endemic (>8% HBV-carriers).4 Japan, Middle East, Mediterranean countries and East European nations are moderately endemic (2-8% carriers); other regions in these zones, South-Europe, and some South American areas have 10–60% carriers.3US, Australia, other South American regions, and Western and Northern Europe have low endemicity (0.5-2% carriers, with 5–7% infected individuals).30
Saudi Arabia has moderate-to-high HBV-rate (>2% carriers).31
A Saudi Arabian research on 8-year hepatitis A/B/C-sero-positivity occurrence trends in the population utilized King Abdul-Aziz Medical City’s surveillance system. Study outcomes depicted average annual HBV-seropositivity occurrence to be 104.6 per 100,000 individuals.31 HBV is estimated to affect over 2 billion individuals globally, with around 360 million suffer chronic infection, and acute illness and mortality risks (primarily from HCC and liver cirrhosis). Mathematical modeling projected annual global HBV-associated deaths in 2000 at around 600,000.27

1.3.1.3 Prevention and control
Key interventions for reduction/prevention of HBV’s global prevalence concentrate on highly-endemic, developing nations; the leading intervention has three components: behavior change for control/reduction of infection spread, active immunization, and passive immunoprophylaxis. HBV-vaccine’s first generation, obtained from inactive plasma was introduced in 1982; in 1986, its second generation became available to public.32-33The vaccine forms the core of HB-prevention (95% effectiveness).34The WHO, in 1991, recommended it to all babies, particularly in countries with ≥8% carrier prevalence.35 It is administered in 3 doses across a 6-month duration (0-1-6).
HCWs in contact with patients’ body fluids/blood must be HBV-vaccinated in three doses. Anti-HB tests must be conducted for recording immunity after 1–2 months post-immunization: 
• Positive: ≥10mIU/mL (milli-international units per milliliter) anti-HBs indicate that HCW is immune and requires no additional immunization/serologic testing.
• Negative: <10mIU/mL anti-HBs indicates HBV-vulnerability, necessitating revaccination (another 3 doses), followed by retesting anti-HBs. If retest also indicates negative outcomes, individual is non-responder. 
Non-responders are HBV-vulnerable and must be extra-cautious and take HBIG prophylaxis after probable/known HBV-exposure.1 Non-responders may (possibly) already be HB-carriers, and should be tested. HBV-affected HCWs must be guided and evaluated medically. 
Immunized HCWs (untested 1-2 months post-original-immunization) don’t require regular anti-HBs testing, unless exposed to body fluids/blood. HCWs with negative outcomes are at risk.
1.3.2 GLOBAL SITUATION
A 2002-03 U.S. cross-sectional research for ascertaining HCWs’ HBV-vaccination coverage and policies surveyed, systematically, 425 out of 6,116 hospitals belonging to the American Hospital Associations. Of 75% surveyed HCWs, 81% nurses/physicians, 71.1% phlebotomists and 70.9% nurse aides/other patient-care personnel received ≥3 HBV-vaccine doses.79.5% white HCWs and 67.6% black HCWs received immunization. Low-risk HCWs who only required inoculation were considerably less-covered (76.6%) than at-risk HCWs (exposed to potentially-contaminated substances).36
Cross-sectional research on Greece’s military hospitals for estimating HCWs’ HB-immunization and establishing coverage-linked factors gave 245 nurses from seven military hospitals self-administrated questionnaires. 75.5% respondents self-reported vaccine coverage; RNs’ coverage was more than nurse aides’. Positive beliefs/attitudes were associated with immunization acceptance/compliance; HCWs were aware of HBV being a crucial occupational hazard. Results proved the need for increased coverage/compliance, through developing targeted immunization programs for non-vaccinated, at-risk HCWs.37
Another similar 2006-08 Greek study interviewed 338 Korinthos General Hospital specialists (59.8% nurses, 19.5% physicians, 7.4% technical services personnel, 6.5% cleaning personnel, and 3.8% administrative staff) before testing, followed by providing additional written data and administering a questionnaire. It addressed vaccination history for several vaccines. 58.6% respondents received HB-vaccination: 47.6% tested positive for anti-HB, while 1.2% showed HB-infection. 27.5% participants were tested for Tuberculosis, out of which 28% showed positive results. 15.4% received Tetanus vaccination, 6.5% tested positive for Anti-HBc, and 0.3% were Anti-HCV-positive.38
A 2010 Brazilian cross-sectional, analytic research verified incidence and factors linked to HB-vaccination among PHCWs (physicians, dentists, nurses, community healthcare agents, oral health and nursing assistant/technicians). A form was used to procure socio-demographic, behavioral, occupational, and general health data from 797 PHCWs. 762 PHCWs responded (95.6%); all but one of these (95.5%) answered the vaccination question, 52.5% reported completion of three doses and 47.5% received incomplete immunization. Older hired workers reported low immunization prevalence, consumed alcohol, and failed to update their occupational health knowledge; more educated staff and members exposed to sharp instruments revealed higher prevalence.39
A 2010-11 KwaZulu-Natal hospital descriptive, observational research determined HB-immunity of sharp-object-injured HCWs, and assessed their attitude/knowledge regarding HBV-immunization. Participants were handed structured questionnaires; results were: 67 of 78 doctors (respondents) suffered sharp-object injuries, out of which 39% weren’t HB- immunized, while 19% were administered HB-immunoglobulin. 65% respondents suffered ≥1 injury; 56% didn’t know their HB-immunity status; 31% were administered a booster dose in the last 5 years; 90% conceded that PEP (post-exposure prophylaxis) for HBV was equally vital as prophylaxis for HIV. 84% respondents agreed that anti-HB testing was crucial after an injury. Respondents’ HBV-knowledge was poor- 67% underestimated HB-transmission risk; only 33% knew of it. 61% doctors (22% unknown, 39% known) weren’t HBV-immune.40
A 2005 cross-sectional Indian study aimed at evaluating HCWs’ HBV-immunization status and examining reasons for non-compliance. 254 susceptible HCWs (nurses, medical assistants, housekeepers, and paramedics) had to answer a set questionnaire for acquiring relevant information and ascertaining vaccination coverage. Findings were: 57.5% respondents were HBV-immunized; housekeepers showed least vaccine compliance; mean vaccinated-HCWs’ age was 30.5years, while 34.3% non-compliant individuals were aged 30+; 32.2% completed primary immunization following a decade in healthcare settings. 83.3% respondents cited reasons for non-compliance (risk-related beliefs/knowledge were key factors). 31.1% claimed vaccine non-accessibility as cause for dose-incompletion; the most prevalent reason cited was absence at vaccine drives (owing to temporary duty/leave).41
A cross-sectional study of 485 public/private sector HCWs in rural Tehsil Swabi, Northwest Pakistan in 2010 evaluated their vaccination status, investigated facilities and discovered personal characteristics linked to vaccination coverage. A questionnaire obtained socio-demographic information, and data on HBV-vaccination, knowledge of transmission modes, perceived vaccination benefits and disease severity. Participants were chosen from 483 primary healthcare centers (447 private, 36 public). 75% participants were physicians; the rest were dispensers. Mean HCW age was 38 years (10.4), while average experience in the field was 12.2 (8.6) years. 40% respondents self-reported complete immunization. HBV-immunization prevalence was: 41% physicians; 37.7% dispensers. Public HCWs showed higher vaccine compliance (76.8%) than private workers (35.4%). Qualified physicians showed highest coverage (86%) while dispensers without formal qualification showed lowest coverage (16%).42
HCWs from 2 Georgian hospitals in Kaspi and Batumi underwent a cross-sectional survey, in 2007, for measuring HBV-vaccination rates and determining vaccine compliance factors among them. They were given self-administered questionnaires with questions on demographic characteristics, HB-immunization status, vaccination barriers, and inclination to recommend HB-vaccine to peers. Lab tests identified HB-infected, immune and at-risk individuals. 91% HCWs responded (173 nurses, 124 physicians). Vaccine coverage was 12%; 54% participants agreed to recommend it to peers; 72% regarded the vaccine as safe (out of which 70% recommended it to others). 66% HCWs perceived cost to be an obstacle to vaccination, and believed it was imperative to offer free/economical vaccination. Probability of recommendation was linked to coworkers’ completion of vaccination. 37% formed attitudes and acquired knowledge on the vaccine from a harmful-event reporting mechanism, 27% from medical literature, 22% from vaccine testing for identifying contaminants, 7% from vaccine effectiveness reports.43
1.3.3 REGIONAL SITUATION
A 2011 cross-sectional Libyan research for assessing HCWs’ HBV-vulnerability and vaccine compliance surveyed 2705 HCWs for HBsAg and anti-HBs via a standardized self-reporting questionnaire, for obtaining demographic, HB-vaccine status and non-compliance information. Overall 78.1% respondents were immunized; 82.6% were administered ≥1 dose, and 72% received all three doses; 17.4% never received HB-vaccination. Paramedics showed highest vaccination coverage. Mean HB-surface-antigen prevalence was 1.1%, while that for anti-HBc was 17.3%.44
A descriptive, cross-sectional HCW survey for evaluating their attitudes, behavior and knowledge regarding HBV-protection/transmission was conducted in Kuwait’s capital, and Farwaniya Governorate, in 2011.A specially-designed questionnaire drawn from other published research was administered to 534 individuals; response rate was 55% .76.2% respondents knew that HBV can be transmitted to them via patients; 57.7% knew that worker-to-patient transmission was also likely; 81.5% knew of vaccination; 65% had information on overall vaccination schedule; and 44.4% had knowledge regarding the time gap between doses.74.7% PHCWs reported being vaccinated– of these, 84% received complete vaccination, 73.8% reported to requiring more information on the disease, and 79.3% individuals never vaccinated  had no specific cause for missing immunization.45
A 2008 cross-sectional Syrian University Hospitals’ research on HCWs’ HBV-immunization status, for outlining prevention priorities based on institutional injury data and highlighting the risk of sharp-object injuries, chose participants via computerized randomization. A self-formulated researcher-administered questionnaire on 316 HCWs showed the following results: 76.6% HCWs received ≥1 needle-stick injury in one year; 23.4%  were non-immunized; 56.1% completed vaccination course; and 20.6% were incompletely-immunized. Housekeepers, a high-risk group, depicted low HBV-vaccine coverage (4.5%).46
1.3.4. NATIONAL SITUATION
A local cross-sectional study endeavored to assess Hajj-time HCWs’ (Arafat and Mina nurses and doctors) compliance in obtaining HBC, meningococcal, and influenza immunization. Anonymous, self-administered, researcher-supervised questionnaires obtained demographic/ vaccination history-related information. 392 HCWs enrolled in Hajj-medicine training; response rate was 100% (45.2% doctors, 54.8% nurses). 82.4% HCWs were meningitis-immunized, 5.9% were influenza-immunized, 66.3% were administered complete HBV course (of these, 51.5% were anti-HB-tested post-vaccination). 12.2% received only two HB-vaccine doses, 7.1% received only one dose, and 14.3% were non-immunized. No significant difference was seen between nurses’ and doctors’ compliance.17
A 2012 cross-sectional survey at Faculty of Dentistry, King Abdul-Aziz University, assessed HBV-vaccination coverage and infection controls among Saudi dentists. A questionnaire for obtaining information on post, service length, demographic data, HBV-vaccine status, anti-HB tests, needle-stick-injury history, disease history, and infection control precautions was administered to 402 dentists (226 female, 176 male). 80.5% received HB-immunization; 48.5% reported needle-stick injuries; none reported HBV-infection. Younger dentists used protective wear religiously and got vaccinated. A link was found between vaccination and protective barriers, but not between vaccination and needle-stick injuries.16
1.4 Study rationale
HBV represents a key occupational hazard because of enhanced exposure to HBV-transmitters. The Saudi occupational health division recommends, but doesn’t mandate, HBV-vaccine for HCWs. HCWs have a choice in getting vaccinated, and this hinges on their attitude/knowledge concerning HB-vaccination. There has been no such prior research in the country.
2.1. Aim and objectives
1-To identify HBV coverage of Al-Madinah Al-Munawarah’s PHCWs
2-To ascertain PHCWs’ knowledge regarding HBV-vaccination
3- To discover PHCWs’ attitudes regarding HBV-vaccination. 
4- To determine obstacles to HB-vaccine coverage of PHCWs.
2.2. Research Questions
1-What are the reported HB-vaccination coverage levels among Al-Madinah’s PHCWs?
2-What is their attitude and knowledge concerning HBV-vaccine?
3- What obstacles impact PHCWs’ HBV-coverage?
2.3. Research hypothesis
Around 50% of PHCWs had been administered all three HB-vaccine doses.
3.1 Study Design 
A descriptive cross-sectional research was carried out, via a quantitative method; a self-administered questionnaire was given to subjects.
3.2 Study Setting 
 The research was performed at Al-Madinah Al-Munawwarah, in January-June, 2014. Al-Madinah has 43 government health facilities with 1200 PHCWs.
3.3 Sample and sampling method
Sample size
Size was estimated, using the hypothesis of 50% HBV-vaccine coverage with 3% precision degree, to be 384 PHCWs, via stratified random sampling, out of 645 PHCWs.
Formula for determining sample size: n= (Z2pqD)/d2
Where n=Sample size  
Z=Standard normal deviate (1.96 at CI 95%).
p=Estimated target population covered (0.50).
q=I-p (remaining target population) 
d=Level of significance (0.05) 
D=Desired effect (1). 
N= (1.962x0.50x0.50)/0.052=384.
Sampling method
There are 4 administrative divisions in Al-Madinah. The 645 HWCs were proportionally allocated among sectors depending on the PHC centers per sector. 43 PHCCs exist in Al-Madinah [Therefore, 645/43=15, multiplied by total PHCCs in individual sectors gives HWCs chosen from each]. Average of HCWs in individual PHCCs in individual sectors was utilized for determining number of PHCCs to be studied; PHCCs were chosen randomly.
Inclusion criteria:
1-HCWs having job experience of over 6 months
2-PHCWs available during data collection  
3-Health Professionals from PHCCs
3.4 Study Population
Every qualified PHCW, who satisfied the aforementioned inclusion criteria, serving at Al-Madinah’s government PHCCs and willing to participate in the research were included. 
3.5 Data Collection Tools/Methods
A structured, self-administered, anonymous questionnaire, developed in English and translated into Arabic was used. Pilot study and to-and-fro checks were applied for ensuring validity. Both English and Arabic questionnaires were distributed among PHCWs.
The questionnaire explained survey significance, participation significance, voluntary participation, respondent benefit, confidentiality and estimated completion time. Questions were clarified before participants.
Questionnaire delivery was ensured via appointments with subjects through their manager. Willing participants were given the questionnaire. Completed questionnaires were gathered at pre-arranged times. A 3-time verbal reminder for completion and return was given, failing which, respondent was assumed to be unwilling, and replaced. The questionnaire had 4 sections:
1: Demographics: Participant gender, age, nationality, job category, and job experience (years). 
2: Knowledge: Participant knowledge of HBV-vaccine’s significance, effectiveness, complete dosage, route of immunization, and time gap between doses (months).
3: Attitude: Views on occupational risk from HBV; mandating of HBV-vaccination; perception of personal risk because of precautions during patient-contact and procedures; perception of pain inflicted by vaccine [on a 5-point strongly disagree--strongly agree scale]
4: Practice: Protection from and exposure to HBV; immunization; number of doses administered; immunity check post-vaccination; contaminated sharp-object injury history; obstacles to vaccine completion/administration.
3.7 Data Analysis
Study utilized Microsoft Access for entering gathered data; analysis was done via EPI INFO.  PHCWs’ vaccine coverage attitudes, knowledge and obstacles to completion/administration was analysed through descriptive analysis. Statistical analysis controlled probable confounders. Tables, bar charts and pie charts displayed study results. Five questions assessed HBV-vaccine-related knowledge on a 0-5 scale [<2=poor; 2-4=moderate; 4-5=good). Correct replies scored 1, while wrong replies/’Don’t-knows’ were marked 0.  
HCWs’ attitudes were measured through four questions, via Likert scale [positive statements: 0=strongly disagree, 5=strongly agree; and negative statements: 0=strongly agree, 5=strongly disagree]. Overall potential scores scaled from 0-20 [Negative attitude: 0-11; neutral attitude: 12-15; positive attitude: 16– 20].
3.8 Study Validity
A pilot study on 20 participants was done for testing questionnaire reliability, question validity, clarity, and information validity. These participants were omitted from final study due to sensitization to questions. Formulation of questionnaire was done such that all variables’ elements (attitudes, knowledge, and coverage) were accounted for, guaranteeing content validity.
3.9 Ethical Considerations
Research Ethics Committee 14/4014/IRB of King Saud University’s Institution Review Board gave ethical consent for the study (Research Project No.E-14-1077) Al-Madinah’s Directorate General of Health Affairs approved the study. A separate respondent consent form explicitly indicated voluntary participation, and stated research summary (title, goals, and objectives), societal benefits, and respondents. Identification details of respondents weren’t sought, thereby ensuring confidentiality and anonymity.
4.1 Response rate
645 questionnaires were among all PHC sectors of Al-Madinah [Northern sector (4 PHCCs, 135 HCWs), Southern sector (6 PHCCs, 165 HCWs), Western sector (7 PHCCs, 165 HCWs), and Eastern sector (7 PHCCs, 180 HCWs). HCWs were randomly chosen based on inclusion criteria. 542 completed questionnaires were returned; thus, response rate was 84% [54% nurses, 14.8% physicians, 14.8% other specialty health workers, 8.1% pharmacists, 4.6% dentists and 3.7% laboratory technicians] (Figure 1).
 
4.2 Descriptive statistics 
4.2.1 Respondents’ socio-demographic characteristics  
Most participants were Saudi nationals (90.6%), aged 23-63 (mean age=34.3 years, SD=7.37), and male (57.7%). In terms of occupation, nurses constituted the majority sample (54%). Experience in the sector was from 1-37 years (mean=10.6 years; SD=7.4). Sector-wise, majority participation was by eastern sector HCWs (26.8%) (Table1)
 






 
4.2.2 PHCWs’ HBV-vaccine coverage
73.8% HCWs received complete vaccination, 15.9% were incompletely immunized, and 10.3% never received vaccination (Table3). 89.7% reported to being administered no less than one dose (Table2); 81.1% completed three doses; 9.3% completed two doses; 4.9% were only administered one dose; and 1.2%  received >3 doses (Fig3). Of the 48.1% HCWs with anti-HB testing history (Table4), 95.3% tested positive (Table5). 

  

 
 
 
 
4.2.3 HBV-vaccination-related knowledge
Scores were on a 0-5 scale (mean=3.93; SD= 1.03). 74.2% respondents possessed high knowledge; 23.1% possessed moderate knowledge; 2.7% possessed weak knowledge (Table6).
Table 6 depicts HCWs’ knowledge levels; clearly, most participants were aware of HBV- vaccine’s significance (96.5%), 48% knew its effectiveness, 90.4% knew number of doses for total protection, 82.5% knew HB-route, and 76.2% were familiar with time gap between doses (Table7).
 
 4.2.4 HCWs’ attitudes towards HBV-vaccination 
Actual overall score range indicated good overall attitude (mean=16.23, SD=2.02). 67.2% depicted positive attitude, 31% depicted a neutral attitude and 1.8% showed negative attitudes (Table8). Table 9 depicts answers distribution to questions on attitude. 
 
 4.2.5Needle stick/sharp-object injury occurrence and instrument type
39.7% respondents reported to sharp-object injuries at work, and 60.3% reported no injuries (Table10). Needles caused 88.8% injuries, blades caused 7.9% injuries and other sharp instruments caused 3.3% injuries (Figure4). Nurses reported highest number of sharp-object injuries (69.3%) (Table11). 

 
 
 4.2.6 Vaccination Barriers 
36% respondents cited shortage of time as reason for failure to get immunized; 34.5% indicated negligence, 14.8% reported lack of awareness, 7% reported fear of adverse effects, 6.3% reported others obstacles and 1.4% reported unimportance of vaccine in their view as reasons for non-compliance (Table12)

 Discussion
5.1 RESPONSE RATE
This study’s response rate was 84%, lower than that of a Georgian study (91%) 43, and higher than that of a Kuwaiti study (55%) on the same subject.45 Response rate results adequately represent target population, with frequent researcher-respondent interaction at the workplace. 
5.2 Vaccination coverage
The study showed satisfactory vaccination coverage/acceptance; 89.7% HCWs received ≥1 dose and 73.8% were administered full course (3+ doses). Vaccine coverage in Saudi HCWs is higher than in a Brazilian (52.5%) and North-Indian study (40%),39-49 and in line with a 2010 Pakistani study (73.42%).47 48.1% HCWs with vaccination history undertook anti-HB testing, a percentage lesser than the Hajj-time study (51.5%).17HBV-immunity among vaccinated respondents was 95.3%, much higher than the percentage in the Libyan study (71.2%). Only 10% respondents reported non-immunization48 The Saudi Ministry of Health gives free HB-vaccines to all HCWs.
5.3 Knowledge
96.5% study respondents knew HBV-vaccine’s significance, 90.4% knew correct vaccine dosages for total protection, and 76.2% had knowledge of time gap between doses- a percentage greater than that depicted by the Kuwaiti study.45 PHCWs probably obtained this information via an infection control initiative in all of Al-Madinah’s PHCs. 
5.4. Attitude
The study showed encouraging results with regards to HBV-vaccine-related attitudes; 67.2% participants reported positive view, 70.8% believed their job made them HBV-susceptible, as opposed to 81.5% respondents of the Kuwaiti study.46 83.4% HCWs strongly believed in the need for mandating HBV-vaccine for all HCWs; 61.2% disagreed/didn’t strongly agree to not being HBV-susceptible due to precautions during patient-contact, a finding similar to that of a Texas research.50 47% respondents strongly disagreed/disagreed that HBV-vaccine may cause harm (distrust of vaccination), akin to the percentage of a Swedish study.51
5.5 Occupational exposure
39.7% participants reported needle-stick/sharp-object injuries at work, as opposed to results of a Syrian study (76.6% with ≥1 injury in previous year), 46 and 67.9% for an Egyptian study.52
5.6 Vaccination Barriers
Non-immunized/incompletely-immunized respondents cited time constraints (36%) and negligence (34.5%) as key barriers. This result is in line with that of an Indian study (41.6% due to negligence).49A Georgian study reported main barrier to HBV-vaccine as concerns regarding vaccine safety.43
5.7 Study Limitations
Bias-induced errors were minimized via a statistically-powerful sample. Respondent anonymity and consent form collection prior to questionnaire administration ensures questionnaire validation. Recall bias is likely as past experiences are needed. For error reduction, the study employed random sampling and increased sample size.
6. 1 Conclusion
There is still a need for improved HBV-vaccine coverage among PHCWs. Coverage is affected by lack of knowledge/awareness, attitude, etc. PHCWs’ high infection transmission risks necessitate increased protection for them, which may be achieved through enhanced vaccine availability, free-of-cost to all HCWs. Completion of full HBV-immunization course must be made compulsory for HCWs prior to job commencement. National guidelines and policies endorsing mandatory HBV-vaccination should be implemented.
6.2 Recommendations
1-Increase HCWs’ HBV-vaccine-related knowledge
2-Increase HCWs’ vaccination coverage (particularly dentists and nurses)
3-HBV-related education must continue targeting HCWs with negative attitudes.
4-Offer anti-HBs testing post-vaccination and improve PHCWs’ adherence to it.
5-Strengthen HCW supervision on good workplace practices

REFERENCES

1- World Health Organization. Hepatitis B: World Health Organization Fact Sheet 204. 2000.http://www.who.int/mediacentre/factsheets/fs204/en/
2. Gust ID. Epidemiology of hepatitis B infection in the Western Pacific and South East Asia. Gut 1996;38(suppl:S18-S23
3-WHO.Department of Communicable Diseases Surveillance and Response. Hepatitis B. Available from: URL: http://www.who.int/csr/disease/hepatitis/HepatitisB_whocdscsrlyo2002_2.pdf
4- Zanetti AR, Van Damme P, Shouval D. The global impact of vaccination against hepatitis B: a historical overview. Vaccine 2008; 26: 6266-6273
5- Global Immunization Data, October 2009. Available from: URL: http://www.who.int/immunization_monitoring/data/en.
6-Mahoney FJ. Update on diagnosis, management, and prevention of hepatitis B virus infection. ClinMicrobiol Rev 1999;12:351-366.
7-Lee WM. Hepatitis B infection. N Engl J Med 1997; 337:1733-1745.
8-World Health Organization. Hepatitis B: World Health Organization Fact Sheet 2013.
9- Workers’’ IoHc. Recommendation of advisory committee on immunization practice (ACIP) and the Hospital Infection Control Practice Advisory committee (HICPAC). MMWR, Recommendation and report 26; 12/26/97.
10- al-Turki KA, Abu-Gad HA. Frequency of and prevention measures for needle-stick injuries among hospital healthcare workers in Saudi Arabia, J Healthc Qual. 2000;22(6):23-8.
11-Updated US Public Health Service Guidelines for the Management of Occupational Exposure to HBV, HCV and HIV and Recommendation for Post exposure Prophylaxis. MMWRRecomm Rep 2001; 50(RR11):1-52.
12- Prüss-Üstün A, Rapiti E, Hutin Y. Sharps injuries: global burden of disease from sharps injuries to health-care workers. Geneva. WHO, 2003 (WHO Environmental Burden of Disease Series, No. 3).
13- Mahoney FJ. Update on Diagnosis, Management and Prevention of Hepatitis B Virus infection. ClinMicrobiol Rev 1999; 12 : 351-66.
14- Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD: Guideline for infection control in health care personnel, 1998. AJIC ., 26:289-354.
15 - Centers for Disease Control and Prevention: Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the HospitalInfection Control Practices Advisory Committee (HICPAC). MMWR 1997, 46(RR-18):1-42.
16- Ayman A. Al-Dharrab, PhD, Khalid H. Al-Samadani, PhD. Assessment of hepatitis B vaccination and compliance with infection control among dentists in Saudi Arabia, www.smj.org.sa Saudi Med J 2012; Vol. 33 (11).5:1205_1210
17- Tariq A Madani*1,2 and Tawfik M Ghabrah3.