Aim: The aim of the study was to compare the level of awareness on Hepatitis-B infection among medical and dental interns in Pondicherry, India. Materials and Methods: Questionnaire containing a set of 20 different questions on Hepatitis B infection was distributed among 64 Medical and 49 Dental Interns of Arupadai Veedu Medical College and Mahatma Gandhi Dental College, Pondicherry, India, respectively. Results: The majority of interns (94.7%) were aware that Hepatitis B virus is the major cause of Hepatitis. About 33.6 and 59.3% of interns had very good and moderate knowledge respectively. The study shows that dental interns (34.7%) had better awareness than medical interns (32.8%). About 52.2% believed that Hepatitis B virus can be transmitted by semen and vaginal secretions. Only 39.9% of the interns believed that doctors, dentists infected with HBV should not have direct contact with patients. Conclusion: One- third of the interns had very good knowledge about Hepatitis B. The majority had good knowledge regarding the mode of transmission and attitude towards HBV patients. However, there is a misconception about prophylaxis, vaccination and treatment of HBV. Hence there is an imperative need for health education to improve the knowledge and attitude of the interns towards Hepatitis B.
Keywords: Hepatitis B, interns
Hepatitis B Virus (HBV) infection is a global public health problem. Nearly two billion people in the world have been acutely infected by HBV and there are nearly 350 million people chronically infected.  Of these 350 million at least one million die annually from HBV-related chronic liver diseased, including cirrhosis and liver cancer.  However, the significance and magnitude of the problem vary from country to country.
While the prevalence of HBV ranges between 5-10% in South East Asia and one per cent in Northern Europe and America, the situation in India is somewhere in between with nearly 3-4% of the population infected by the virus.  HBV is 50 to 100 times more infectious than HIV.  In India, about four per cent of the population were estimated to be HBV carriers giving a total pool of approximately 36 million carriers. 
Hepatitis B is caused by Hepatitis B virus (DNA virus). Hepatitis B is the most serious type of viral hepatitis. The case fatality rate is approximately one per cent. Acute disease causes symptoms like nausea, vomiting, abdominal pain, fatigue, dark urine, yellowing of skin and eyes. Hepatitis B is transmitted by contact with blood, body fluids and sexual contact with infected individuals. Hepatitis B virus does not spread by contaminated food or water, and cannot spread casually in the workplace.
High rate of HBV infection occurs in spouses of acutely infected persons, sexual promiscuous individuals, persons who require repeated transfusion and health care personnel exposed to blood. The highest incidence of disease is in younger adults, and most HBV infections are acquired through unprotected sex with HBV-infected partners or through shared needles used for injection drug use.  Because of highly sensitive virologic screening of donor blood, the risk of acquiring HBV infection from blood transfusion is one in 2,30,000. 
A study on transmission of HBV from a surgeon to his patients suggests that a surgeon with hepatitis B may have infected 28 of his patients with hepatitis B virus.  The first serological marker to appear in serum is HBsAg. On disappearance of HBsAg, antibody to HBsAg (anti- HBsAg) appears in the serum. Other serological markers are anti-HBc, HBeAg and anti-HBe. The most serious complication of viral hepatitis is fulminant hepatitis, hepatitis B accounts for more than 50% cases of fulminant viral hepatitis. The other most important complication is the risk of hepatocellular carcinoma. About 80% of Indian patients with hepatocellular carcinoma have hepatitis virus associated liver disease.  No specific treatment is available for acute illness caused by Hepatitis B. Antiviral drugs are approved for the treatment of chronic hepatitis B.
Chronic hepatitis B in some patients is treated with drugs like interferon or lamivudine. However, therapy costs thousands of dollars. Hence it is preferable to prevent this disease by administration of Hepatitis B vaccine. The Hepatitis B vaccine is effective in preventing hepatitis B and hepatocellular carcinoma due to chronic Hepatitis B infection.
In Pondicherry, there are seven medical and two dental colleges. Of them, Arupadai Veedu Medical College (AVMC) and Mahatma Gandhi Dental College (MGDC) were chosen by a simple random technique; 70 and 53 questionnaires were distributed to interns at AVMC and MGDC respectively. However, 64 from AVMC and 49 from MGDC returned the questionnaire with complete answers.
Of all the respondents, 43.3% were from the dental college while 56.7% were from medical college. The mean age of the study population was 24 years (22-27 years). The questionnaire consists of 20 different statements concerning basic knowledge of HBV, its modes of transmission, risk behavior, prevention, treatment, belief and attitude towards HBV infected individuals. The first set of 10 statements were based on the knowledge of epidemiology and different modes of HBV transmission such as contracting HBV through semen and vaginal secretions, from mother to unborn child and through breast milk.
Interns were questioned whether HBV could be transmitted through sharing the same plate used by an infected individuals or by hugging an infected individuals. The second set of 10 questions dealt with vaccination, prophylaxis, treatment and chance of iatrogenic infection. Scores equal to or greater than 15, 10 to 14 and less than or equal to nine were considered good, moderate and worse respectively. When analyzing level of knowledge for significance, moderate and worse were clubbed with poor level of knowledge.
Responses to the questionnaire were in the form of agree, disagree and not sure. The data was completely collected in July 2008 and analyzed statistically using statistical package for social science program (SPSS 9.0 for Windows).
The study showed that 33.6% of the study population had good knowledge about Hepatitis B [Table 1]. Dental interns (34.7%) had marginally better knowledge than medical interns (32.8%) and when analyzed it was not significant (p > 0.05). The level of awareness for mode of transmission and treatment was calculated [Table 2] and [Table 3], 64.6% of them had good knowledge about mode of transmission. Medical interns had better knowledge (73.4%) when compared with dental interns (53.1%).
Following analysis, the difference was found to be significant (p < 05). Surprisingly, only 11.5% of the study population had good knowledge about treatment options available for Hepatitis B. Dental interns had better awareness (18.4%) when compared with medical interns (6.3%) which was totally unexpected. When the same was analyzed it was found significant (p < 05).
The overall response for each questionnaire is given in [Table 4]. The majority of interns (94.7%) were aware that HBV is a common cause of Hepatitis. Of them, 100% of medical interns were aware, whereas only 87.7% of dental interns answered this question correctly. The attitude towards HBV infected individuals regarding transmission of HBV through sharing of same plate was answered correctly by 84.1% of interns. Of them, medical (90.6%) and dental (75.5%) answered correctly.
Since there is much difference, chi-square test was applied and found to be significant (p less than 05). The interns had very less awareness about transmission of HBV through semen (52.2%) and vaginal fluid (52.2%). The level of medical interns was surprisingly less when compared with dental interns; when the difference in knowledge was analyzed by chi -square test it was found to be not significant (p > 05). The level of knowledge of transmission of HBV to child from mother through breast milk was 62%. Since greater disparity was found between the two groups, medical (71.9%) and dental (49%) interns, it was analyzed by chi-square test and found to be significant (p < 05).
The interns had, unexpectedly, less knowledge regarding treatment of HBV through drugs. The level among medical interns was surprisingly less when compared with dental interns. Hence chi- square test was done to confirm the authenticity of the difference between the two groups and confirm if was true or by chance. The difference was found to be highly significant (p < 001). Only 39.9% of the interns believed that doctors, dentists infected with Hepatitis B virus should not have direct contact with patients. The dental interns (53.1%) surprisingly had better awareness than the medical interns (29.7%), hence chi- square was applied and found to be significant (p < 05).
Interns understanding the cause of death of HBV infected patients was pitiable (30.1%), with medical interns (39.1%) showing better understanding than dental interns (18.4%). Analysis was found to be significant (p < 02). About 92.9% of the interns knew of a vaccine to prevent HBV and 83.2% had HBV vaccination. Most of the interns (more than 80%) correctly answered questions on screening blood donors for safe transfusion, transmission by sharing the same plate, hugging or handshaking, coughing, sneezing, needles for piercing and pregnant women to fetus. Interns also had good knowledge (more than 80%) about sterilization of instruments for HBV infected individuals, investigating all patients undergoing major surgery for HBV and about vaccination to prevent HBV.
In India there are 283 medical colleges and around 30,000 students join every year. Our study involved the interns of a medical and dental college; AVMC and MGDC. The interns were expected to have sufficient knowledge on the modes of transmission and treatment of HBV. These interns represent the physicians and dentists who would graduate and practice medicine and dentistry from next year. Therefore, they are expected to play an imperative role in limiting the increasing number of HBV infection cases and in promoting health education in India.
There are many factors associated with negative attitudes towards HBV infection. These include: less liberal ideology, a low knowledge level, young age, fear, exaggerated risk assessment, not knowing someone with HBV infection and lacking the experience of caring for patient with HBV infection.  Although, the overall results of the study and the knowledge regarding mode of transmission of HBV was good, knowledge about treatment of HBV was poor.
Our study showed that only 92.9% of the interns were aware of HBV vaccine, which is less when compared with a study conducted by the Department of Dental Surgery and Periodontology at University of Dundee, Dundee, which showed that 99.2% of the medical and dental students were aware of immunization of HBV.  About 67.4% of the dental interns who participated in the study were willing to treat an HBV infected patient. A study in Taiwan showed that 80% of dental students were willing to treat HBV infected patients. 
Significant differences were observed between medical and dental interns for the following modes of transmission: sharing same plate (p < 05), semen (p > 05), vaginal secretions (p > 05) and breast milk (p <05), in treatment of HBV through drugs (p < 001), treating a HBV infected individual (p < 05) and cause of death (p < 02). The overall immunization for HBV virus is only 83.2%, which is very low. A study on medical students’ exposure to blood and body fluids revealed that 48% of all graduating medical students recalled being exposed at least once to potentially infectious body fluids during their last two years of medical school. 
A recent American study revealed that 32.8% of dental students reported experiencing occupational exposures to blood or other potentially infectious materials. Of these, 39% reported two or more exposures each.  So, the medical universities should take necessary action to inform, educate and vaccinate the health professionals who were at risk.
The Ministry of Health should make HBV vaccination mandatory for all health professionals. There is a false impression about prophylaxis, vaccination and treatment available for HBV. Though knowledge alone is not sufficient to bring about behavioral changes there is an imperative need for health education to remove misconceptions. This can be done by well structured health education programs, seminars, workshop and conferences.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]