Background: Healthcare workers (HCWs) have a high risk of hepatitis B virus (HBV) infection. The prevalence of HBV among HCWs in hospitals in developing countries is high. However, the vaccination status of these workers in hospitals in Haldwani city is not well documented. Objectives: The aim was to assess the hepatitis B vaccination status among HCWs in a tertiary care hospital in Haldwani city of Nainital, Uttarakhand, India. Materials and Methods: In this cross-sectional study, 367 HCWs were randomly selected. Information pertaining to demographic and vaccination status was collected by interviewing them with the help of predesigned and pretested interview schedule. Result: The overall proportions of complete, incomplete and unvaccinated respondents with hepatitis B vaccine were 48.5%, 21.8%, and 29.7% respectively. In relation to designation of respondents, 35 (53.8%), 65 (77.4%), 61 (51.7%), 12 (40.0%) and 5 (7.2%) of respondents who were residents, interns, nurses, technicians and nursing attendants respectively had received Hepatitis B vaccination as against those who had partially received and not received vaccination and this differences were statistically significant. The most common reason for acceptance of vaccine was protection against Hepatitis-B infection (39.9%) and the commonest reason for not getting vaccinated was negligence (43.1%) Conclusion: These results conclude that because of low immunization coverage, HCWs are at greater risk of getting Hepatitis B infection at the hospital.
Keywords: Health care worker, Hepatitis B, vaccination
Hepatitis B virus (HBV) infection is the tenth leading cause of death in the world and about one-third population of the world (2 billion) are infected with HBV and among them 350 million are carriers.  15-40% of the infected individuals develop cirrhosis, liver failure or hepatocellular carcinoma. India is categorized under the intermediate prevalence zone for HBV carrier and estimated prevalence between 2% and 7%. The projected figure for hepatitis B surface antigen positive individuals in India is 50 million, and data indicates that 5-10% of HBV infected workers become chronically infected. ,
Over the last several decades, the incidence of HBV infection has been decreasing because immunization has assumed a primary role as a control strategy. Hence realizing its necessity, the government of India has included Hepatitis B vaccine in National Immunization Program and expanded to entire country in 2010, but there are no national polices and guidelines advocating and supporting mandatory HBV immunization among health care workers, who are at highest risk of getting the infection.  Acceptance of vaccination by health care workers is an essential issue for hospitals from India. There is a few data available on hepatitis B vaccination status of health care workers especially among interns and resident doctors that’s why we have planned to conduct this study.
To assess the hepatitis B vaccination status among healthcare workers (HCWs) in a tertiary care hospital in Haldwani city of Nainital, Uttarakhand, India.
This cross-sectional study was carried out from January to December 2013 in the Department of Medicine, Government Medical College Haldwani, Nainital, Uttarakhand. The study population consisted of resident doctors, interns, nurses, technicians and nursing attendants working in the hospital and gave consent to participate in the study. Sample size was calculated to be 369 taking the immunization coverage as 60% and absolute precision of 5%. Of 369 respondents, 367 health workers were included in the study, and two uncooperative participants were also excluded from the study. A self-administered, pre-structured questionnaire consisting of designation, age, gender of respondent and questions regarding the status of hepatitis B vaccination and reasons for vaccine acceptance and refusal or incomplete immunization, was given to all participants of Dr. Susheela Tiwari Government Hospital and Government Medical College, Haldwani. The participants were explained the objective of the study and an informed consent was taken from each of the participants.
Complete immunization refers to who received three doses of hepatitis B vaccination at 0, l and 6 month, Partially or Incomplete immunization refers to who received 1 or 2 dose of hepatitis B vaccination and not immunized means, who had not received any dose of vaccine.
Systat 12 was used to analyse the data (Cranes Software International Ltd. Serial No: 797071898) The results were presented in the form of frequency and proportion. Chi-square test was used to study the significance of the difference between proportions. P ≤ 0.05 was considered to indicate statistical significance.
The overall proportions of complete, incomplete and unvaccinated respondents with hepatitis B vaccine were 48.5%, 21.8%, and 29.7% respectively, as depicted in [Figure 1]. The mean age of respondents was 33.40 ± 5.3 years. [Table 1] shows that the proportion of complete vaccination among younger or elder group are more while maximum respondents among age group 31-50 years were unvaccinated, and this difference was found to be statistically significantly (P = 0.001). The proportion of complete vaccination was found higher in females (54.5%) when compared to males (42.2%) while incomplete and unvaccinated was expressed higher among males as compared to females (25.6% vs. 18.2%) and (32.2% vs. 27.3%) respectively, and the differences were statistically insignificant (P = 0.052).
[Table 1] also shows that in relation to designation of respondents, 35 (53.8%), 65 (77.4%), 61 (51.7%), 12 (40.0%) and 5 (7.2%) of respondents who were residents, interns, nurses, technicians and nursing attendants respectively had received hepatitis B vaccination as against those who had partially received and not received vaccination and this differences were statistically significant (P = 0.001). Based on the length of work, 125 (70.6%), 48 (33.3%), and 05 (10.9%) of health workers in ≤5 years, 5-10 years, and >10 years category respectively had received hepatitis B vaccination as against those who had not received hepatitis B vaccination and unvaccinated this difference was statistically significant (P = 0.001).
[Table 2] shows the reasons for acceptance of hepatitis-B vaccine among respondents. The most common reason for acceptance was protection against hepatitis-B infection (39.9%) followed by availability of vaccine at cheaper rates (31%).
[Table 3] shows the reasons given by the respondents who did not get vaccinated. The most common reason was negligence (43.1%) followed by lack of motivation (39.44%). About 2% of respondents told that they do not believe in immunization.
Hepatitis B is a well-documented occupational hazard for health care workers, including both doctor and paramedical personals. It is estimated to affect at least 2 billion individuals worldwide and 350 million among them are suffering from chronic HBV infections.  Since the development of an effective vaccine against hepatitis B, vaccination is the best way by which one can arm oneself against HBV infection. Transmission rate of HBV is as high as 30% in those who are not immunized but rare in those who have been immunized. 
This study shows that 178 (48%) of participants were completely immunized, whereas 80 (22%) were incompletely immunized, and 109 (30%) had not received any vaccine. In a study conducted at AIIMS New Delhi, it was reported that out of 446 health-care workers, 224 (50%) health care workers were completely vaccinated and 28 (6%) had received incomplete vaccination.  In another study conducted at G. B. Pant Hospital New Delhi, stated that out of 2162 health care workers, 1188 (55.4%) were vaccinated against HBV.  Our findings are almost similar with these studies.
Among different cadres of health care workers in this study reported that highest vaccination rate was seen in interns (77.4%) and least in nursing attendants (7.2%) [Table 1]. This difference of immunization can be explained on the basis of their awareness for the disease and educational status. Similar results of vaccination rates were reported by Shrestha and Bhattarai  and Imam et al.  The young health-care workers were more likely to be vaccinated; this observation was made by Resende et al.  Similar observation reported in our study that 77.4% of interns and 53.8% of resident doctors were vaccinated against HBV. An interesting observation also noted in our study that increased vaccination rate was not associated with length of work experience. This finding was in contrast to other studies where it was found that increased working experience and advanced age were significant factors in the higher rate of vaccination.  This could be explained by that higher qualification, more knowledge about disease and vaccine, directly associated with vaccination. In a study done AIIMS New Delhi, 96% doctors were vaccinated against hepatitis B.  The low uptake of hepatitis B vaccination in one particular group like the nursing attendants identified in our study, and it could be attributed to low education, poor socio-economic status and absence of Hospital-Policy for hepatitis B vaccination.
In our study, we also tried to find out the reasons that were possibly responsible for acceptance and non-acceptance of HBV among HCWs. The acceptance of the vaccine was strongly related to good knowledge about HBV infection, the safety and efficacy of the vaccine [Table 2]. A similar observation was also by noted by Bradley and Kristi, that acceptance of HBV Vaccine is strongly related to knowledge about HBV disease and HBV Vaccination.  In our study, the main reasons for non-acceptance of vaccine were negligence (43.11%), followed by lack of motivation (39.44%) [Table 3]. A study conducted in Nigeria reported that workers with the highest knowledge of, and exposure to the hepatitis B infection within the hospital setting, that is, doctors, nurses, and laboratory staff, showed the greatest apathy toward the immunization program.  Another similar observation was also noted in a study that a lower perception of risk among doctors was the main reason for poor vaccination. 
It is concluded in our study that a significant number of HCWs were not immunized with Hepatitis B vaccine, and the immunization coverage was very low with various categories of paramedical staff, like nursing attendants and technicians. Thus, in order to prevent Hepatitis-B infection, education program should be focused on the transmission of infection, complete three doses of hepatitis B vaccination, pre and post-exposure prophylaxis and also aggressive campaigning to improve their immunization status.
[Table 1], [Table 2], [Table 3]