Awareness and accessibility of Hepatitis B vaccination among undergraduate clinical students of a tertiary institution in South Eastern Nigeria

Hepatitis B virus Infection is a chronic Infection with increasing incidence and worldwide prevalence. It is a leading cause of liver failure and hepatocellular carcinoma. Healthcare personal, chronic blood transfusion, unprotected sex, etc are some major risk factor of contracting the disease. It can be prevented by vaccination. This study was carried out among undergraduate Clinical students of college of Health Science, Nnamdi Azikiwe University (CHS-NAU), Nnewi it was a cross-sectional descriptive study using the convenience sampling method. Pretested self-administered questionnaires were distributed and the data analyzed using the statistical package for social science (SPSS) Version 20.0. A total of 178 questionnaires were distributed with a response rate of 100% (178). The study showed a high level of knowledge of HBV vaccination and consider attitude towards the need for vaccination but poor compliance to update due to busy schedule, cost, and level of study. HBV vaccination is low among the students of a CHS-NAU as in other parts of Nigeria and Africa with similar reasons. Good Policy enactment and implementation can help bridge the gap between the awareness, attitude and accessibility of vaccine.


Introduction
Hepatitis B Virus infection, is a major global problem affecting large number of people every year. Hepatitis B Virus primarily targets the liver and can cause both acute & chronic liver diseases. HBV infection is asymptomatic in majority of the people and the chronic infection may lead to serious complications such as cirrhosis of the liver, & hepatocellular carcinoma. As per the Latest World Health Organization (WHO) report dated July 18, 2018; globally by the end of 2015, an estimated 257 million people were living with HBV and approximately 887,000 deaths have occurred mainly because of chronic complications of HBV infection.
HBV infection is an occupational hazard, and the risk of health care workers and clinical medical students getting infected is 2-10times higher than in other general population, medical students must have proper knowledge about HBV infection, modes of transmission, clinical features, complication & preventive measures. The proper knowledge helps them take necessary precautions measures to prevent getting infected and also to create awareness about HBV infection, among the public and other health care workers [1].
Vaccination and use of personal protective equipment's are the two major weapons for the prevention of hepatitis B infection. Recombinant HB vaccine which is licensed for use is advised for all health care workers and clinical medical students [3].
More than 1 billion doses of hepatitis B vaccines have been given worldwide and it is considered one of the safest & most effective vaccines ever made. Though common side effects may include; soreness, swelling and redness at injection site. The vaccine may not be recommended for those with documented history of adverse reaction to the vaccine [4].
HBV is hyper endemic in Nigeria and arguably the highest in Sub-Saharan Africa. This is coupled with the fact that it is highly transmittable at the initial stage of the infection even without clinical symptoms and signs [5].Amongst Clinical Medical Students /health care workers, zero prevalence is two or four times higher than that of the general population. They remain at high risk of acquiring HBV infection mainly through percutaneous or mucosal exposure to infected blood or body fluids [6].
As a result of subclinical course, the disease runs at the initial stage of infection most of the time, there is also the risk of transmitting infection to patients by the apparently healthy looking medical student. The widespread diffusion of HBV with its accompanying cost implication in prevention, management and treatment in a low -income country like Nigeria poses a heavy burden for government and health -care providers [5].
In a study in Pakistan in 2011, it was reported that the vaccination coverage of HBV among medical students was low in spite of the availability and accessibility of a cost-effective vaccine [7]. Another study showed that there are significant immunity gaps against all vaccine preventable diseases among healthcare students in Athens, Greece [8]. In 2015, a study by Okwesili et alrevealed a high prevalence of HBV infection among Biomedical Students in Sokoto, Nigeria [8].Hepatitis B, being an object of public health concern ought to be adequately known and properly handled by students training to be health personnel in various capacities first to preserve their own health and prevent undue medical expenses and also to curtail cross-transmission to one another or to patients in their care together with its legal implications.
The objective of the study was to determine the level awareness, accessibility and barriers to uptake of hepatitis B vaccine among under graduate clinical medical students in a tertiary institution in south east Nigeria.

Study area
The study area was Nnamdi Azikiwe University Teaching Hospital. It is a Federal hospital that trains medical students, paramedical Students, Nurses and Resident doctors. The hospital is located at Nnewichi Nnewi and the college of Health Sciences, Nnamdi Azikiwe the college and has somepre-clinical students (200-300level), who stay at Okofia and the clinical student (400 -600L) who stay within the hospital premises. The study population is the clinical medical students.

Study design
This study is a cross -sectional and descriptive study.

Study tool
Self-administered questionnaire was used.

Study population
This study was carried out among the clinical students of the Nnamdi Azikiwe University Teaching Hospital.

Inclusion criteria
All bona fide clinical students of the Faculty on Medicine, Nnamdi Azikiwe University was included.

Exclusion criteria
Post graduate, suspended or rusticated students of the faculty were excluded from the study.

Sample size determination
Minimum sample size was determined using

Sampling method /technique
The sampling method used was convenient sampling technique. Self-administered questionnaire was taken to each student and shared randomly to members present in the location at the sampling time.

Data Collection/Tools
Data were collected within 2 weeks interval. The questionnaire had four sections; informed consent, participant's demographics, information on Awareness of hepatitis B vaccine and accessibility towards hepatitis B vaccination. The participants' demographics assessed include age, gender, state of residence and geographical zones, ethnicity, religion, marital status and level.

Statistical Analysis
Analysis was performed using the Statistical Software Package SPSS version 20.0.Descriptive statistics (including means and standard deviations) were calculated for the numerical variables.

Ethical consideration
The entirety of the study with focus on the objective and techniques involved were explained clearly to each participant and an informed consent was obtained. The participants were assured of the confidentiality and anonymity of all information that will be supplied in the study.
The participants were also given the freedom to withdraw from the study at any point with an assurance that their decision would not affect my decision to render medical services to them in the future.

Results
The mean age of the respondents isFifty nine point zero percent (105) (12) received two doses.Sixty-one-point two percent (30) had their first vaccination after sexual exposure, 20.4% (10) had theirs voluntarily while 12.2% (6) received their first dose immediately after admission. Forty three point eight percent (14) did not receive HBV vaccine due to busy schedule, forty point six percent [13] did not receive due to unavailability while 25%(8) did not receive due to cost. Seventy nine point three percent (96) are willing to receive HBV vaccine while 19.8%(24) are not sure.

Conclusion
There is a wide gap between the awareness of HBV Infection, importance of vaccination against it, the willingness to be vaccinated and the accessibility of the vaccine among clinical students of College of Health Science, Nnamdi Azikiwe University (CHS-NAU), Nnewi campus. This outcome however is different from the result obtained in other parts of world like Europe where there are good policies for childhood vaccination.

Limitation of study
 Unwillingness of participants to respond appropriately to the research or properly fill the questionnaires.  High financial implication  Non availability of a previous work on the same subject matter within the locality of my study area for comparative analysis.
Recommendations  There should be increased awareness of HBV infection and importance of vaccination through the television, radio, and internet media which are among the easiest means of communication to the wider population.  Policy for infant vaccination against HBV should be enacted and implemented.  HBV Vaccination should be made mandatory for all health students upon admission or at least upon clinical or laboratory exposure.  Vaccination should be scheduled for the students so as to prevent lack of vaccination due to a busy schedule.
 HBV vaccination should be made free or affordable and accessible for all.

Disclosure of conflict of interest
Authors declare that there is no competing interest.

Statement of informed consent
The guidelines on research involving the use of human subjects according to Helsinki declaration was adhered to. Online consent was obtained from participants. Participants were allowed to leave the survey at any time they desired. Confidentiality of information was assured, and the survey was anonymous.