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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 106-114

Knowledge, practice, and awareness of dental undergraduate and postgraduate students toward postexposure prophylaxis and needlestick injuries: A descriptive cross-sectional institutional dental hospital study


1 Department of Conservative Dentistry and Endodontics, Dr Z. A. Dental College, A.M.U, Aligarh, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Paras HMRI Hospital, Patna, Bihar, India

Date of Submission16-Feb-2020
Date of Decision25-Apr-2020
Date of Acceptance07-May-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
Sharique Alam
Department of Conservative Dentistry and Endodontics, Dr. Z.A Dental College, A.M.U, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_4_20

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  Abstract 


Background: The aim of the present study was to assess the knowledge, awareness, and practice of dental undergraduate, interns, and postgraduate students toward postexposure prophylaxis (PEP) and needlestick injuries.
Materials and Methods: A cross-sectional, questionnaire-based survey was carried out among undergraduate, interns and postgraduate dental students in an institutional dental hospital in India. The students were required to fill a self-administered questionnaire with close ended questions with responses indicated by a simple tick box format. The questionnaire was divided into three sections intended to collect information on (1) sociodemographic characteristics, (2) knowledge, and (3) practice habits toward needlestick injury (NSI) and PEP of the respondents.
Results: An adequate score (>70% correct response) to knowledge about NSI and PEP was obtained by 60.2% (50/83) of the respondents, while 47% (39/83) of the student participants obtained an adequate score (>70% score) to appropriate practice habits toward NSI and PEP. A high proportion (84.3%) of the student were vaccinated against Hepatitis B virus, but only 6% were aware of their serum antibody to HBsAg. 61.5% of the student reported experiencing NSI during clinical practice with 3.6% of the students taking PEP. The most common reason for not taking PEP was ignorance of PEP protocol (27.7%) and lack of support to report the incidence (18.1%). The postgraduate students scored better than the undergraduate students in both the knowledge and practice parameters, but the results were not statistically significant (P > 0.05).
Conclusion: This study shows that dental students' knowledge, practice, and awareness toward NSI and PEP is inadequate. The current classroom education must be supplemented with additional interventions to ingrain appropriate practice habits.

Keywords: Dental students, infection control, needlestick injury, post exposure prophylaxis, sharps injury


How to cite this article:
Fatima A, Alam S, Iftekhar H, Tewari RK, Nisar Andrabi SM, Faraz AA. Knowledge, practice, and awareness of dental undergraduate and postgraduate students toward postexposure prophylaxis and needlestick injuries: A descriptive cross-sectional institutional dental hospital study. J Oral Res Rev 2021;13:106-14

How to cite this URL:
Fatima A, Alam S, Iftekhar H, Tewari RK, Nisar Andrabi SM, Faraz AA. Knowledge, practice, and awareness of dental undergraduate and postgraduate students toward postexposure prophylaxis and needlestick injuries: A descriptive cross-sectional institutional dental hospital study. J Oral Res Rev [serial online] 2021 [cited 2021 Dec 2];13:106-14. Available from: https://www.jorr.org/text.asp?2021/13/2/106/319022




  Introduction Top


Healthcare workers and dental professionals can be exposed to blood or body fluids through the mucous membranes and penetrating skin injury while performing their professional practice.[1] The Centre for Disease Control and Prevention (CDC) identifies needlestick injury (NSI) as the greatest risk for transmission of blood-borne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) in the healthcare setting.[2] The Health Protection Agency, UK has reported that NSI accounted for 71% of occupational exposure to blood-borne infection.[3],[4]

The risk of infection from sharp injuries ranges from 2.7% to 10% for Hepatitis C, 5%–45% for Hepatitis B and 0.3% for HIV.[5] The magnitude of risk depends upon the injury characteristics (location, depth, extension) and the viral load of the infected patient.[3] The World health report estimates that 37.6% of hepatitis B, 39% of hepatitis C, and 4.4% of HIV/acquired immunodeficiency syndrome (AIDS) among Health Care Workers are due to NSIs.[6]

The routine use of sharp instruments in the restricted working space of the oral cavity contaminated with blood, saliva and secretions makes the dental health care professional prone to percutaneous injury.[6],[7],[8],[9] NSIs can happen during local anesthetic administration, recapping the needle or while disposing of the needle.[10] Percutaneous injuries from burs, hand instruments and other sharp instruments also constitute a risk factor in transmitting infection in the dental operatory. While the importance of training and awareness to infection control protocols and handling of sharps cannot be overemphasized, dental health personnel should also be aware of the protocols to adhere to in case needlestick or sharp injury does take place.

Postexposure prophylaxis (PEP) refers to comprehensive medical management to minimize the risk of infection among health care personnel following potential exposure to blood-borne pathogens (HBV, HCV, and HIV).[11] The sequence of protocol initiated should include (1) immediate washing of the injured site with soap and water without scrubbing, (2) assessment of the risk of transmission of infection with the exposure, (3) evaluating the source patient for HIV, HBV and HCV infection, (4) initiation of PEP with appropriate antiretrovirals or immunoglobulin if source patient is infected and (5) evaluation and follow up of the health care personnel.[1]

PEP should be started as soon as possible, preferably within the golden period of <2 h. Studies have demonstrated that initiating antiretroviral therapy within 1–2 h after suffering percutaneous injury by a needle contaminated with an HIV positive patients' blood may reduce the risk of HIV transmission by 81%.[12] In case of exposure to hepatitis B infection, PEP must be administered to nonvaccinated individuals and individuals not achieving a satisfactory antibody response of 10 mIU/ml after vaccination. PEP for Hepatitis B includes administration of Immunoglobulin for passive immunity followed by scheduling for Hepatitis B vaccination.[13],[14] The CDC reports that the risk of HBV transmission after exposure to HBsAg positive blood can be reduced by nearly 75% by the appropriate PEP administration.[15],[16] No PEP is available for Hepatitis C; however, early treatment of acute Hepatitis C may prevent chronic Hepatitis C infection.[14]

Cheng et al.[17], in a survey study, reported that 23% of dentists in Taiwan suffered from more than one percutaneous sharp injury per week. A cross-sectional study on Iranian medical and dental students reported an incidence of 74.3% of NSIs.[18] Several studies report gross underreporting and adherence to postexposure protocols by dental professionals in case of percutaneous injury.[4],[19] The dental students in India working in an overburdened hospital setting are vulnerable to blood-borne infectious exposure. They should be aware of the preventive and prophylactic measures to be taken should such an event occur. The present survey questionnaire study was conducted to evaluate the knowledge, practice, and level of awareness regarding NSI and PEP among dental undergraduate and postgraduate students in a dental institute in India.


  Materials and Methods Top


Study population

This cross-sectional survey questionnaire study was conducted between December 20, 2019 and January 10, 2020 amongst the undergraduate dental students, interns, and postgraduate dental students of Dr Z. A Dental College, A. M. U, Aligarh. The undergraduate (third, final year and intern students) and postgraduate students enrolled in the Faculty of Dentistry, A. M. U and involved in clinical patient handling were included in the study. Undergraduate (first- and second-year students) and postgraduate students (nonclinical postgraduate students, research associates) not involved in the clinical patient handling, faculty staff members overseeing the dental students, dental health personnel not involved in the capacity as a student, auxiliary dental healthcare workers, dental nurses and technician were excluded from participation in the study. The study protocol was reviewed and approved by the Research Ethics committee of the hospital.

The dental students eligible to participate in the study included 71 undergraduate students encompassing third year (25 students), final year (24 students) and interns (22 students), and 30 postgraduate students across a range of disciplines including endodontics, oral surgery, periodontics, prosthodontics, pedodontics, and orthodontics. The dental students were explained the objective of the survey questionnaire and assured of the anonymity and confidentiality of the information provided. The completion and submission of the questionnaire form was considered as consent to participate in the study. A total of 83 dental students responded to the questionnaire (63 undergraduate and 20 postgraduate students).

Questionnaire

The eligible dental students were provided the questionnaire and required to answer a self-structured questionnaire with closed ended questions with responses indicated by a simple tick box format. The questionnaire was prepared from CDC guidelines and by modifying questions from other published survey studies.[20],[21] It was reviewed by selected dental professors affiliated with Dr. Z. A Dental College before the commencement of the study. The reliability of the questionnaire was determined by a pilot study on ten dental faculty members by obtaining responses to the questionnaire form twice at an interval of one week. The reliability of the questionnaire was deemed to be good, with a Cronbach's α of 0.84. The questionnaire was divided into three sub-sections.

Section A

This section comprised the collection of socio-demographic characteristics like age, gender, level of education and field of specialization if any.

Section B

This section consisted of ten questions to assess the knowledge about PEP, preferable time to take PEP, duration of PEP, knowledge about the PEP guidelines and needles and sharps disposal. All questions were close-ended questions. When respondents correctly answered ≥70% of the ten knowledge questions, they were considered to have adequate knowledge. When <70% of the questions were correctly answered, respondents were considered to have inadequate knowledge.

Section C

This section consisted of ten questions to assess the practice of dental undergraduate, interns and postgraduate students toward needlestick injuries and PEP. Students who responded to more than 70% of the questions correctly were considered as having an adequate practice habit. The questions seeking general information like exposure to HIV patient during dental practice and questions not applicable to the individual candidate were not scored. The scoring was determined individually based on the eligible scored questions for each candidate.

Statistical analysis

The answers to the questionnaire were evaluated and scored manually. The data obtained were entered into Statistical Package for Social Sciences (SPSS) version 25.0, IBM Corp., Armonk, New York, USA for data analysis. The variables were dichotomous or categorical, and the results were tabulated in the form of percentages and frequencies. The association between the student cohorts (third year, final year, intern, and post graduate students) and adequate response score was assessed by Chi-squared test.


  Results Top


Out of the total 101 questionnaires distributed to the students, 83 questionnaires were received back. The overall response rate was 82.2% with 88.7% (63 of the 71 students) of the undergraduate and 66.7% (20 of the 30 students) of the postgraduate students responding to the questionnaire. The mean age of the study participants was 24.2 ± 2.1 years (male 24.8 ± 2.4, female 23.2 ± 1.7), and the male to female ratio of the respondents was 1.37 [Table 1].
Table 1: Demographic characteristics of the participants

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Knowledge and awareness of dental students regarding postexposure prophylaxis

An adequate score (>70% correct response) to knowledge about NSI and PEP was obtained by 60.2% (50/83) of the respondents. 80% post graduate student respondents (16/20), 61.9% (13/21) of the intern respondents, 59.1% (13/22) of the final year and 40% (8/20) of the third-year student respondents obtained an adequate score to the knowledge section of the questionnaire. The Chi-squared test statistic revealed a statistically nonsignificant result between the student cohorts (χ2 = 6.72, df = 3, P= 0.08) [Graph 1].



11.9% (9 students) were unaware of the term and meaning of PEP with 3rd year students forming the majority of the unaware respondents (6 students). Hundred percent of the postgraduate students were aware of the term PEP. 44.5% (37/83) of the student correctly responded that patient's blood should be evaluated for HIV, HBV and HCV infection in case the healthcare worker suffered a percutaneous injury. The majority of the students (55.4%) were aware that PEP would be maximally effective if administered within 1 h of the percutaneous injury. When asked about the duration of PEP for HIV, 27 students (32.5%) responded correctly, i.e. PEP should be continued for 4 weeks, and a significant proportion of the students (43.3%) admitted to not knowing the duration of PEP. 32.5% of the students responded correctly that a Hepatitis B vaccinated healthcare worker should know/determine his antibody status to HBsAg. A nonresponder with inadequate antibody to HBsAg would need PEP if he/she was exposed to Hepatitis B infection. 43.3% of students were aware that no PEP is available for Hepatitis C, and early treatment initiation could prevent chronic hepatitis C infection and its complication. 49students (59.0%) knew that needles and sharps should be discarded in the white bin. Regarding the knowledge about PEP guidelines, 51 students (61.4%) were unaware of any guidelines. Only 16% of the students responded that they were equipped to handle a blood-borne exposure to viral infection in the dental clinic [Table 2].
Table 2: Knowledge and awareness about needlestick injury and postexposure prophylaxis

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Practice status of students regarding needlestick injury and postexposure prophylaxis

Forty-seven percent (39/83) of the student participants obtained an adequate score (>70% score) to appropriate practice habits toward needlestick injuries and PEP. The frequency of the third year, final year, intern and postgraduate students obtaining an adequate score was 40% (8/20), 45.5% (10/22), 47.6% (10/21) and 55% (11/20), respectively. The association of practice habits with student cohorts was assessed by Chi-squared test, which indicated a statistically nonsignificant relationship (χ2 = 0.93 df = 3 P= 0.8) [Graph 2].



A high proportion of the students, 84.3% (70/83), were vaccinated against Hepatitis B, but only 6.0% (5/83) were aware of their postvaccination Hepatitis B antibody titer. 27.7% of the students reported compliance with universal precautions while treating all their patients. Fifty-three percent reported that they may not always comply with universal precautions due to the high patient load. 28.9% of the students have treated patients with a known history of either HIV, HBV or HCV infection. A significant proportion of student had experienced NSI (61.5%) during clinical practice, with 3.6% of the student taking PEP following the accident. All the students cited exposure from a known HIV/HBV patient as the reason for taking the PEP, and no student reported taking PEP when they were exposed to NSI from a patient with an unknown HIV/HBV status. The most common reason for not taking PEP was ignorance of PEP protocol (27.7%) and lack of support to report the incidence (18.1%). 62.7% of the students were willing to report needlestick injuries however, 71.1% of the students were unaware of the appropriate person/authority to contact in the event of NSI [Table 3].
Table 3: Practice toward needlestick injuries and postexposure prophylaxis among students

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  Discussion Top


Sharps injury poses a serious concern for transmission of blood-borne infectious diseases, especially HIV, HBV and HCV infection. Dental students in India work in an overburdened, resource limited health care setting and may be prone to occupational infectious diseases. Knowledge and implementation of practice policies for needlestick injuries and PEP amongst the students can limit the risk of transmission of infectious disease. CDC and National AIDS Control Organization advocate PEP for HCW with needlestick injuries from a known infected source or a source with unknown infection status.[22] This survey study was conducted to assess dental students' awareness and practice habits toward NSIs and PEP in an institutional dental hospital.

The present study reports that 89.1% of the student participants were aware of the term PEP. An adequate score (judged by >70% correct response) to knowledge and awareness of NSI protocol and PEP was obtained by 60.2% of respondents. The level of awareness is comparable to other hospital based studies conducted in countries like South Africa,[21] Ethiopia[23] and India.[22] A study conducted by Westall and Dickinson[4] in Kings College hospital in London has reported greater awareness and compliance than reported in the present study. This difference can be attributed to the Kings College policy of implementing personal protective equipment campaigns, mandatory lectures, and formal assessment for students as part of the infection control training program.

PEP should be preferably administered within the 1st h to be maximally effective. However, it can be administered within a maximum delay time of 24–72 h, after which its effectiveness in preventing infection decreases considerably. This is because HIV does not infect the dendritic cells in the mucosa and skin at the injury site immediately, but it occurs gradually over the first 24 h. PEP within the 1st h of exposure severely limits the proliferation of the virus in the dendritic cells or lymph nodes and prevents systemic infection.[22],[24] 55.4% of the students were aware that the PEP should preferably be initiated within the 1st h for maximal effectiveness, which is higher than that reported by Kasat et al.[22] and Chacko and Isaac[25] in studies conducted on interns and postgraduate students in India. The awareness was, however, lower compared to studies by Angadi et al.[11] conducted on general dental practitioners and Agaba et al.[26] conducted on physicians. PEP for HIV should be continued for 4 weeks following exposure from an HIV infected source. In the present study, 32.5% of the students knew of the correct duration of antiretrovirals to be taken as HIV PEP. This more than that reported by Kasat et al.[22] (23.4% interns and 25% postgraduates), Chogle et al.[24] (6.0% among surgical and anesthetic residents) but considerably less than that reported by Okoh et al.[21] (63% among dental surgeons) and Agaba et al.[26] (83.3% among family physicians). 40.9% of the students were aware that the immediate step after NSI should be washing the hands with soap and water. Guruprasad and Chauhan[10] reported that only 12% of the students were aware of the need to immediately wash the hands with soap and water after NSI. A majority of the students in the present study (61.4%) admitted that they were not aware of any guidelines on NSI and PEP. Only 19.2% of the students responded that they were confident and aware of taking the necessary steps after occupational infectious exposure. This indicates that the students should be made aware of the guidelines and protocols, and activities beyond the academic curricula should continuously re-enforce them.

Regarding the practice toward needlestick injuries and PEP, adequate scores (>70% correct response) was obtained by 47% of the students. The practice section of the survey questionnaire was scored individually on the number of applicable questions for each respondent. The individual scoring was adopted for obtaining an accurate score percentage as some questions did not apply to certain respondents. The practice section scores obtained by all the student cohorts (3rd year, final year, interns, and postgraduates) were less than the knowledge section scores. This can be attributed to the real world constraints in implementing an acquired knowledge in a practical setting as well as attitude of the students in comprehending the serious implications. The students' primary impediment in reporting NSI in this study was unawareness of the hospital protocol for PEP (27.7%) and lack of support to report the incident (18.1%).71.1% of the student were unaware of the name/position of the appropriate person to contact for reporting a NSI.

In the present study, 84.3% of the students reported being vaccinated against Hepatitis B, but only 6.0% of them were aware of their post vaccination Hepatitis B antibody titer. A study by Shaghaghian et al.[1] conducted in Shiraz, Iran, reported a higher prevalence than in the present study. They reported 100% vaccination, with 33% of the dentists being aware of their post vaccination antibody titer. The dissimilarity in the study population of young dental students in the present study compared to practicing dental practitioners in the study by Shaghaghian et al.[1] could be a reason for the difference in prevalence. The present study indicates that the students were unaware of the importance of checking the post vaccination antibody titer. Serum antibody to HBsAg (anti-HBs) level is crucial for deciding the need for PEP in a vaccinated individual after a blood borne exposure from an infected source. The CDC guidelines state that a vaccinated individual with serum anti-HBs <10 mIU/mL would be considered a nonresponder. If a nonresponder individual is exposed from a known HBsAg positive source or from an unknown source with high-risk status; in that case, the recommended HBV PEP is to administer Hepatis B immunoglobulin (0.06 ml/kg intramuscularly) followed by reinitiating vaccination.

CDC has recommended universal precautions as a measure to reduce occupational exposures. As it is not possible to determine the infection status of every patient prior to treatment, each patient should be considered potentially infectious, and dental practitioners should comply with universal precautions. The participants' awareness regarding universal precaution in the present study is comparable to studies by Jaber[27] (92.1%) and George et al.[28] (91%). While only 10% of students were unaware of universal precautions, a sizeable number of students (53%) in the present study admitted that they might become negligent with compliance to universal precautions due to the high number of patient load.

61.5% of the students reported suffering a NSI in the hospital workplace with only 9.6% of the student not undertaking PEP due to a negative serologic test of the source patient. The prevalence of NSI in the present study is similar to a study conducted among resident doctors in Mumbai.[29] Lower prevalence of NSI has been reported by Jaber (23%)[27] and Malik et al.(30%).[30] The present study indicates a need to increase awareness toward the incorporation of safe practices on handling and disposing of sharps. Serologic testing to determine the infection status of the exposure source also needs to be emphasized as it can clarify the need for PEP to be administered to the healthcare worker.

The results of the present study indicate that knowledge and awareness of NSI must be supplemented with real-life implementation. The following action is proposed to supplement the current method of classroom knowledge and seminars: (1) Student representative body should be made aware of the guidelines and encouraged to run campaigns to raise awareness about the hospital guidelines (2) Written guidelines with information of responsible authority to contact in case of NSI must be made available to students posted in clinical duties (3) Visually appealing Charts and posters must be placed in the operatory setting (4) the dental college should have a dedicated unit responsible for documenting, supervising and following up the exposed healthcare worker (4) Dentists should be emphasized the serious implications if appropriate measures are not initiated following exposure from an infective source (5) Universal precautions should be strictly enforced while treating every patient (6) Regular audits should be conducted to identify deficiencies and lapses and appropriate corrective actions should be carried out (7) students can be made stakeholders in the audits by involving them in collection and analysis of the data.

The results must be viewed under the limitation of the study being a cross-sectional questionnaire study relying on the respondents' veracity of the response. However, it provides insight into the lacunae and focus areas where further practice-based studies can be carried out.


  Conclusion Top


Dental healthcare workers, including dental students, are at significant risk of occupational infection exposure. This study revealed that the level of knowledge and practice regarding occupational exposure and PEP is inadequate among dental students. Awareness and implementation of infection control practices and PEP need to be prioritized among dental students to seamlessly carry forward appropriate attitudes and practices to safeguard their safety from occupational exposure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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