CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Hepatitis B is a viral infection of the liver that can cause both acute and chronic disease. The
virus is transmitted by contact with a person's blood or other body fluids. In the native
Australians in 1965 the first case of hepatitis B was found (Blumberg, 1967). The first record
of the hepatitis B virus epidemic in 1885 was produced. The world's people have been
infected several times, with chronic infections between 240 million and 350 million people
(Global Burden of Disease, 2014). About 750,000 people die every year from hepatitis B.
(Burden, 2014). Between 5 and 10% of adults are chronically infected in East Asia and Sub-
Saharan Africa. European Councils. The hepatitis B virus (HBV) has infected approximately
2 billion people worldwide, which represents one-third of the world population. Of these
cases, 350 million (5– 7% of the world population) are chronically infected.

Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). It can be
acute and resolve without treatment .Hepatitis A, B, C, D, and E are a category of infectious
diseases caused by viruses. Despite affecting millions of people worldwide and killing nearly
1.4 million people in 2015, it remains largely unknown (CDC, 2015).

Although improved understanding and programs that increase vaccines, blood and
injection protection, and minimize harm can help prevent the virus from spreading, hepatitis
B management in developed countries is still largely inadequate (Drain, 2009). The hepatitis
B virus is 50 to 100 times more contagious than the hepatitis C virus (Thorley, 2008), and it
can live for at least seven days outside the body. The virus can still infect you throughout this
period (Liu, 2002). Preventing disease progression, especially to cirrhosis, liver failure, and
hepatocellular carcinoma, is the primary treatment target for patients with hepatitis B (HBV)
infection (Nguyen2009). Patients with schizophrenia are currently advised to seek treatment.
The prevalence of chronic Hepatitis B virus infection in a given region is reflected in the
primary method of transmission. In low-prevalence areas like the United States and Western
Europe, injection drug addiction and unsafe sex are the most common approaches, though
other factors may play a role as well. The disease is primarily transmitted among children in
moderate prevalence areas such as Eastern Europe, Russia, and Japan, where 2–7% of the
population is chronically infected. Transmission during childbirth is most common in high-
prevalence areas like China and Southeast Asia, though transmission during childhood is also
a major factor in other high-endemicity areas like Africa. 350 million people are believed to
be carriers of the hepatitis B virus worldwide, with 50 million chronic carriers in Africa
(Lavanchy and Daniel, 2016).

Carrier concentrations in Sub-Saharan Africa vary from 9 percent to 20%. (WHO,

2014). In Ghana, the hepatitis B virus is prevalent, with sero10 prevalence rates ranging from
6.7 percent to 10% in blood donors, 6.4 percent in pregnant women, and 15.6 percent in
infants (Sarkodie, 2015). Somalia and Somaliland have seen an increase in the number of
refugees.The high prevalence of the Hepatitis B virus makes it one of the district's most
severe health issues. Despite the fact that the Hepatitis B virus is prevalent in the Borama
District, the management problems have not been investigated. Underweight, unsafe sex,
high blood pressure, tobacco and alcohol intake, and unsafe water, sanitation, and hygiene are
all common Hepatitis B risk factors (WHO, 2002). Other risk factors include socio-cultural
factors and previous hepatitis B infection (Healthy Pregnant Women of New Delhi, 2004).
Pre-existing conditions, such as diabetes, are also included (chronic diseases, acute disease,
and high blood pressure). Factors that prevent these risk factors from being regulated may be
considered.This study conceptualized factors in management of hepatitis B. Personal factors such as
attitude, life style, and health status. Institutional factors such as facilities and equipment, staffing,
quality assurance. Home based factors such as social economic status, gender roles and family
history.
Personal factors are an important first step in improving self-management abilities.
Self-awareness will help you make better decisions and recognise and prevent disease-
infecting situations (Corey, 1993). Institutional influences are those that are established and
enforced by the organization itself (Agrawal, 2001). Home-based influences refer to tools
within the home that form a person's personality and influence decisions and outcomes
(Belcher, 2011). Such factors can increase a person's risk of developing hepatitis B and, as a
result, make it more difficult to handle the disease. Patients with hepatitis B (HBV) infection
have two main treatment goals: prevention and cure.
1.2 Statement of the problem

Hepatitis B infection is a highly resilient, blood-borne and sexually transmitted virus, which
in chronically infected individuals can be found in high concentrations in blood, vaginal
secretions and semen.

Medical students are constantly exposed to the dangers of acquiring hepatitis B due to
contact with blood and body secretions of patients. The risk of contracting HBV by medical
students is four times greater than that of the general adult population who do not work or
practice in healthcare institutions. It is also a well-established fact that an unvaccinated
individual stands the risk of 6% to 30% to acquire the infection on exposure to HBV
contaminated blood or body fluids.

Hepatitis B may occur with limited or no symptoms, but in advanced stages it often leads to
jaundice, anorexia (poor appetite), and malaise. Persistence of hepatitis for more than six
months is classified as chronic hepatitis. Serologic testing for hepatitis B surface antigen
(HBsAg) is the primary way to identify persons with HBV infection. Testing for HBsAg is
recommended for persons who are the source of blood or body fluid exposures that might
warrant post-exposure prophylaxis.

The incidence of HBV infection can be reduced by giving proper education and awareness
regarding its transmission and vaccination to the medical students and health-care workers,
and also there’s no previous researches have been conducted in Borama. Hence, this study
was conducted to assess the knowledge, attitude, and prevention of HBV infection among
medical students in Borama city Somaliland

1.3 Research Objectives

1.3.1 General Research Objective

The purpose of this study is to assess the knowledge attitude and prevention regarding

hepatitis B among medical students at Horn university in Borama city Somaliland

1.3.2 Specific Research Objectives

1. To identify of knowledge of hepatitis B among medical students at Horn university

Awdal Region Somaliland 2021.

2 To determine the attitude of hepatitis B among medical students at Horn university

Awdal Region Somaliland 2021.
3 To assess the preventive of Hepatitis B among medical students at Horn university
Awdal Region Somaliland 2021.
1.4 Research questions
1. What is the knowledge of hepatitis B among medical student?
2. What is the attitude of hepatitis B among medical student ?
3. What is the preventive of hepatitis B among medical student?

1.5 Significance of the study

This research is significant to the following stakeholders the government and hospitals
This study was aimed at generating data from medical students in Borama context which
can help health policy makers and development planners to design and develop
appropriate strategies and programs that can reduce hepatitis B infection and enhance
hepatitis B vaccine by medical students and health care workers. This study is also useful
to academia, especially researcher who may be interested in carrying out empirical
studies.

1.6 Scope of the study

1.6.1 Geographical scope

The study will be carried out in a Borama which is capital city of the largest region in
Somaliland.
1.6.2 Content scope
The content of the study will be the knowledge attitude and prevention regarding
hepatitis B among medical student in Borama district Awdal region Somaliland.
1.6.3 Time scope
The study will be conducted from July 2021 up to august 2021.
1.7 Rationale (Justification)
The rationale behind this study about to determine the Knowledge attitude and prevention
regarding hepatitis B among medical student is important because of hepatitis B virus
(HBV) infection is a major global public health problem which can lead to life-
threatening conditions like liver cirrhosis and hepatocellular carcinoma (meads, 2011)
Medical students are key in prevention of Hepatitis B but can also be a major source of
infection. Despite the availability of the vaccine, adherence to recommendations has not
been as great as initially expected. There have been few researches examining the
Knowledge attitude and prevention regarding hepatitis B among medical student in
Somaliland, while there is no previous researches carried on this variable in Borama so
that this study will be valuable study that help to know more about more about hepatitis
B virus infection. (meads, 2011)
1.8 Operational Definitions
Hepatitis B is a contagious liver disease that ranges in severity from a mild illness lasting
a few weeks to a serious, life long illness. (Pooverawan, 1993, 1990)
Vaccination is the process of artificially administering into human body to get immunity
for the protection of diseases. This may be done either by stimulating the body’s
immune system with the vaccine or toxin to produce antibodies which prevent disease. A
vaccine is a suspension of live or killed organism (i.e., viruses) or parts of organism.
((CDC), 1996).
 CHAPTER TWO
Literature review

Concepts, opinions and ideas from experts related to the study 2.1 Hepatitis B Virus
Hepatitis B Virus (HBV) is a DNA virus and was first identified in the 1960s. According
to the ICTV classification, this virus belongs to the genus Ortho-hepa-dnavirus of the
Hepadnaviridae family and, along with the Spumaretrovirinae-subfamily of the
Retroviridae-family, represents the only other animal virus with a DNA genome known
to replicate by the reverse transcription of a viral RNA intermediate (Seeger et el, 2017).
Hepatitis, inflammation of the liver caused by viruses, bacterial infections, or continuous
exposure to alcohol, drugs, or toxic chemicals, such as those found in aerosol sprays and
paint thinners. Inflammation is the painful, red swellings that result when tissues of the
body become injured or infected, Inflammation can cause organs to not work properly.
Hepatitis can also result from an autoimmune disorder, in which the body mistakenly
sends disease-fighting cells to attack its own healthy tissue (Ganem, D. & Prince, 2014).
The liver is located in the upper right hand side of the abdomen, mostly behind the rib
cage. The liver of an adult normally weighs close to three pounds. No matter what its
cause, hepatitis reduces the liver‘s ability to perform life-preserving functions, including
filtering harmful infectious agents from the blood, storing blood sugar and converting it
to usable energy forms, and producing many proteins necessary for life (Chang, 2017).
Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus
(HBV). It is a major global health problem and the most serious type of viral hepatitis.
Originally known as "serum hepatitis", the disease has caused epidemics in parts of Asia
and Africa, and it is endemic in China, About a third of the world population has been
infected at one point in their lives, including 350 million who are chronic carriers which
causes 620,000 deaths worldwide each year (Edmunds et al, 2014). If your body is able
to fight off the hepatitis B infection, any symptoms that you had should go away over a
period of weeks to months, this is termed acute hepatitis B. some people‘s bodies are not
able to completely get rid of the hepatitis B infection. This is called chronic hepatitis B
(Shepard et al, 2016)
2.1.1 Epidemiology
2.1.1.1 Global Situation of HBV Infection
Hepatitis B, an infectious disease of the liver caused by the hepatitis B virus (HBV), is a
major public health problem worldwide. It is a highly resilient, blood-borne and sexually
transmitted virus, which in chronically infected individuals can be found in high
concentrations in blood, vaginal secretions and semen (Baars et al., 2019).
It is known to remain viable for seven (7) days or longer on environmental surfaces at
room temperature and acute hepatitis B has a long incubation period of up to 90 days on
average during which the individual is. HBV is the prototype member of the
Hepadnaviridae family, genus Orthohepadnavirus of animal viruses (Carreno and
Hubschen et al., 2019). The infection is highly prevalent in Africa and Asia, and in the
different countries, the infection rate ranges from 5% to 20% (Shin et al., 2006). Global
epidemiology of HBV infection is based on prevalence of HBV surface antigen (HBsAg)
in the population. Countries are classified into three categories of HBV endemicity: low
(<2%), intermediate (2- 7%), and high (=8%) prevalence of HBsAg (Dochez, 2018).

HBV infection is a major global public health problem, warranting a high priority for
prevention and control (Baars et al., 2019). Over 2 billion of the world’s population has
been exposed to HBV and an estimated 387 million of these are now chronically infected
with a rate of around 10 million new carriers each year. Approximately 17% of the
carriers will die from the consequences of the HBV infection with an overall annual
mortality rate of about one million. In Sub Saharan Africa (SSA), HBV infection is
endemic. The average carrier rate of the virus in the SSA region is 10% (Baars et al.,
2019). Despite the fact that since 1982 there is a vaccine against HBV that gives 90-
100% protection against infection, there are in the world today more than 350 million
people living with chronic hepatitis B. The consequence of this is approximately 600 000
HBV related deaths every year around the world, where the cause is primary liver
cirrhosis or liver cancer (WHO, (, 2012) In the U.S. approximately 1.4 million residents
are chronically infected with HBV. According to the fact that during the years 1974-2008
17.6 million people born in countries of intermediate or high prevalence of chronic
hepatitis B have immigrated to the U.S., there is an increased burden of chronic hepatitis
B in the country (Weinbaum et al, 2015)
More than half of the estimated chronic hepatitis B cases were from the Western Pacific
region, from countries such as the Philippines, China and Vietnam. These were the main
countries of birth for imported cases of chronic hepatitis B. Africa was the second largest
region for imported cases of chronic hepatitis B. (Mitchell, 2011)

According to systematic review (Rossi, 2012) migrants from East Asia, the Pacific and
SubSaharan Africa represented a high seroprevalence of chronic hepatitis B, 10.3-11.3%,
and migrants from Eastern Europe, Central Africa and South Asia were an intermediate
seroprevalence. The seroprevalence of chronic hepatitis B was low among migrants from
the Caribbean, Latin America, the Middle East and North Africa. Refugees and asylum
seekers had higher seroprevalence of chronic hepatitis B compared to migrants.
2.1.1.2 Hepatitis B - situation in Asia
Even though all humans can be infected with HBV, Asians have the highest proportion
(two thirds) of HBV-infected persons (The hepatitis B foundation, 2013). HBV is
endemic in Vietnam as in many other countries in Southeast Asia and it is the leading
cause of chronic liver disease (Nguyen et al., 2018). Approximately 90% of the infants,
who are infected during their first year, develop chronic liver infections later in life.
About 25% of the adults who developed these infections die from infection related
conditions, such as liver cirrhosis or liver cancer (Nguyen, 2018). According to Bui
(2012), in the article by Nguyen, McLaws and Dore (2017), 8-25% of the Vietnamese
population are carriers of chronic hepatitis B. That is approximately 8.4 million
Vietnamese individuals. It was estimated in the year of 2005 that this resulted in 23 300
HBVrelated mortalities per year in Vietnam. Hipgrave and co-workers (2003)
investigated the prevalence of HBV infection among 1579 individuals (infants, children,
teenagers and adults from 9 months to 40 years old) in rural Vietnam. They found that the
prevalence of current HBV infection was highest among teenagers (20.5%), followed by
adults (18.8%), children (18.4%) and infants (12.5%) and the current or previous
infection increased with age. There was also a slightly higher risk for men to have a
current or previous HBV infection. None of the participants reported that they had
received vaccine against HBV. In a study to foresee the prevalence of HBV and liver
disease in Vietnam by 2025, it was calculated that the prevalence of chronic HBV would
increase until the year 2013 when it would peak at 8.6 million cases. It would then
decrease to approximately 8 million cases in the year of 2025. The decreasing would be
due to the implementation of universal infant HBV vaccinations in 2003. Despite the
increasing amount of infants vaccinated, the projected prevalence of HBV-related liver
diseases will continue to increase during the following two decades due to the long
latency period of the disease’s development. This will result in 40 000 HBV-related
deaths in Vietnam in the year of 2025 (Nguyen, 2018).
2.1.1.3 HBV Situation in africa
In Kenya, HBV is highly prevalent and it accounts for about 60% of the cases with
liver cirrhosis, and for 80% of those with HCC. Around 70% of Kenyans have a positive
HBV serology by adulthood. HBsAg carriage ranges between 8-20% depending on the
province. Moreover, one in every three people in every community in the country is HBV
positive ( (MoPHS, 2018)
2.1.2 Transmission
HBV infection can be transmitted at 3 stages in life; around the time of birth, during
childhood, and in adult life. The main modes of transmission are mother-to child
(perinatal), child-to-child (horizontal), sexual and parenteral. The role of each of these
modes varies across the globe. In developed countries (also countries with low
endemicity of HBV infection) sexual transmission and intravenous drug abuse in
adolescence and adult life account for the majority of cases of HBV transmission, In
developing countries (countries with intermediate and high endemicity of HBV
infection), mother-to-child and child-to-child transmission during the early years of life
are the major modes of transmission of HBV infection. Placental breakdown and leakage
of maternal blood during delivery, in utero infection, and infection postnatally through
breastmilk, babies’ ingestion of blood, and small scratches to the baby during birth are
postulated mechanisms of perinatal transmission (Zuckerman, 2018) Hepatitis B virus is
transmitted between people by direct blood-to-blood contact or semen and vaginal fluid
of an infected person (Hyams, 2016). Modes of transmission are the same as those for the
human immunodeficiency virus (HIV), but the hepatitis B virus is 50 to 100 times more
infectious. Unlike HIV, the hepatitis B virus can survive outside the body for at least
seven days. During this time, the virus can still cause infection if it enters the body of a
person who is not protected by the vaccine (Zuckerman, 2018)
In developing countries, common modes of transmission are:
 perinatal (from mother to baby at birth)
 early childhood infections (in apparent infection through close interpersonal
contact with infected household contacts)
 unsafe injection practices
 unsafe blood transfusions
  Unprotected sexual contact.
 Shared personal items (such as toothbrushes, razors, and nail clippers) with an
infected person. (Zuckerman, 2015)
In many developed countries (e.g. those in Western Europe and North America), patterns
of transmission are different from those in developing countries. The majority of
infections in developed countries are transmitted during young adulthood by sexual
activity, tattoo or acupuncture with unclean needles and instruments, and injecting drug
use (Gane, E. 2015).
Hepatitis B is a major infectious occupational hazard of health and medical students
(Barker et al. 1996). The hepatitis B virus is not spread by contaminated food or water,
and cannot be spread casually in the workplace (McManhon et al., 1985). The incubation
period of the hepatitis B virus is 90 days on average, but can vary from 30 to 180 days (D
´ebarre, 2010). The virus may be detected 30 to 60 days after infection and persists for
variable periods of time (Juszczyk, 2000).
The role of parenteral transmission of HBV infection in health institutions should also be
currently limited due to the routine screening of blood and blood products. However, it
has been reported that in some countries of the Africa hospital or health centre waste
products are not treated in the proper manner and that a lot of these waste products lie on
streets and are accessible to medical students and children who poses a serious health risk
and hazard (Juszczyk, 2000)

2.1.3 Sign and Symptoms

Acute infection with hepatitis B virus is associated with acute viral hepatitis; Symptoms
may not appear for up to six months after the time of infection the early symptoms may
include:
 Appetite loss
 Fatigue
 Fever, low grade
 Muscles and joint aches
 Nausea and vomiting
 Yellow skin and eyes, and dark urine due to jaundice
 swollen stomach or ankles
 Easy bruising
  Tiredness
 upset stomach
 Diarrhea
 light-colored stools (Diekmann et al., 1990)
The illness lasts for a few weeks and then gradually improves in most affected people. A
few people may have a more severe form of liver disease known as fulminant hepatic
failure and may die as a result. The infection may be entirely asymptomatic and may go
unrecognized. (Zuckerman, 2015)
Chronic infection with hepatitis B virus either may be asymptomatic or may be
associated with a chronic inflammation of the liver (chronic hepatitis), leading to
cirrhosis over a period of several years. This type of infection dramatically increases the
incidence of hepatocellular carcinoma (HCC; liver cancer). Across Europe, hepatitis B
and C cause approximately 50% of hepatocellular carcinomas. Chronic carriers are
encouraged to avoid consuming alcohol as it increases their risk for cirrhosis and liver
cancer. Hepatitis B virus has been linked to the development of membranous
glomerulonephritis (Wilson et al., 2016).
2.1.4 Disease States
2.1.4.1 Acute Viral Hepatitis B
Acute Hepatitis infections have a 1 month (4-6 weeks) to as long as 6 months incubation
period after transmission as the virus spreads within the liver. In approximately 65% of
acute infections the infection and resolution is clinically silent. Symptoms that are
clinically recognized in the remaining cases include decreased appetite, nausea and
vomiting, fatigue and abdominal pain as
well as jaundice in the more severe cases. These symptoms most often result from
increased production of pro-inflammatory cytokines such as INF or TNF (Seeger, 2017)
The first serological marker to become detectable during infection is the HBsAg, which
usually becomes detectable at 8-12 weeks post-infection, assuming 1 month incubation.
This marker typically precedes an elevation of serum ALT levels and symptoms of
hepatitis by 2 to 6 weeks and remains detectable throughout the symptomatic phase.
After the onset of jaundice, HBsAgtitres gradually decrease and usually and become
undetectable after 2 to 6 months. Shortly thereafter antibodies against S-antigen (Anti-
HBs) become detectable in the serum and may remain detectable indefinitely (Dienstag
2010). A third serological marker, HBeAg, is readily detectable either concurrently or
shortly after the Santigen. This marker is associated with a period of high levels of virus
replication, more circulating intact virions and detectable levels of HBV DNA in plasma
samples. In self-limited cases, HBeAg levels decrease and become undetectable shortly
after the characteristic peak in serum ALT activity. This coincides with the appearance of
Anti-HBe and a period of lower infectivity with little to undetectable HBV DNA levels,
the most severe cases of acute infection (0.1-1%) lead to complete liver failure and are
termed fulminant hepatitis.
2.1.4.2 Chronic Viral Hepatitis B
Chronic Hepatitis B, or the persistence of HBsAg and HBV disease for more than 6
months, is host and virus dependant and presents in several distinct phases based on
differing levels of viral replication and intensity of the immune response. Carriers
experience an initial immune tolerant phase characterized by near normal levels of ALT,
high levels of HBV DNA and both HBsAg and HBeAg positivity (Dienstag 2010; Seeger
et al. 2017). This phase ends when the immune system matures (in younger carriers) or
recovers and begins to control and clear the virus. The end of the immune clearance (or
immune active) phase is often marked by HBeAg seroconversion when HBeAg levels
become undetectable and Anti-HBe antibodies appear. This is considered a good clinical
sign and marks the beginning of an inactive carrier state because high HBeAg levels are
indicative of high viral replication and infectivity, whereas high Anti-HBe levels indicate
a low level of viral replication with low to moderate infectivity (Seeger et al. 2017)
During this phase the virus causes more severe liver damage while the host immune
system is unable to control the infection, this eventually contributes to liver cirrhosis and
hepatocellular carcinoma (Seeger et al. 2007; Kramvis 2018).
2.1.5 Factors associated with HBV infection
The most common factors found to be associated with HBV infection and carrier status in
the East Africa are family size, socioeconomic status, age, educational status and a
history of previous blood transfusion, surgery or contact with a jaundiced person.
(Gilbert, 1981) The association of a history of jaundice, previous blood transfusions, and
surgery with HBV infection and carrier status has been reported in Jordan, Egypt, Libya
and Yemen. In Yemen, a multi variable analysis found age, a history of jaundice, and a
combined history of blood transfusion and surgery, to be associated with HBV infection
(Scott et al., 1990).
It would be useful to know the nature of these injections and by whom they were
administered. Involvement of non-health personnel may be an important explanatory
factor for infections resulting from these injections. In Egypt, for example, involvement
of non-health personnel and medical students during practice in parenteral and surgical
procedures was found to be associated with a higher risk of HBV infection (Scott et al.,
1990). A large number of surgical procedures such as tattooing and circumcision are also
carried out by unqualified individuals in Egypt, which is the case in many other Middle
Eastern countries and it is important to investigate the role ear piercing and circumcision
may have in the transmission of HBV infection in these countries (Scott et al., 1990).
In Egypt, Ghaffar et al examined risk factors for perinatal transmission. Apart from the
proven importance of HBeAg/ anti HBe status in perinatal transmission, they found that
maternal history of schistosomal infection was significantly associated with perinatal
transmission (Ghaffar et al., 1989). A possible explanation for this association was that
schistosomal infection resulted in impaired cell-mediated immunity, which might
contribute to the presence of a higher titre of HBsAg, and hence increased viraemia and
infectivity (Scott et al., 1990).
2.1.6 Diagnosis
A number of blood tests are available to diagnose and monitor people with hepatitis B.
They can be used to distinguish acute and chronic infections (Xu et al., 1995).
Laboratory diagnosis of hepatitis B infection centers on the detection of the hepatitis B
surface antigen HBsAg. A positive test for the hepatitis B surface antigen (HBsAg)
indicates that the person has an active infection (either acute or chronic) (World Health
Assembly, 1992).
World Health Organization (WHO) recommends that all blood donations are tested for
this marker to avoid transmission to recipients (World health Organization, 2004.)
Other commonly used tests include the following:
Testing for antibodies to the hepatitis B surface antigen – a positive test indicates that the
person has either recovered from an acute infection and cleared the virus, or has received
a hepatitis B vaccine. The person is immune to future hepatitis B infection and is no
longer contagious.
Testing for antibodies to the hepatitis B core antigen – a positive test indicates that the
person has had a recent infection or an infection in the past. Combined with a positive
test for the hepatitis B surface antigen, a positive test usually indicates a chronic
infection. (World Health Organization, 2004; Centre for Disease Control, 2018)
2.1.7 Treatment
Acute hepatitis B infection does not usually require treatment and most adults clear the
infection spontaneously.Early antiviral treatment may be required in less than 1% of
people, whose infection takes a very aggressive course (fulminant hepatitis) or who are
immunocompromised. On the other hand, treatment of chronic infection may be
necessary to reduce the risk of cirrhosis and liver cancer. Chronically infected individuals
with persistently elevated serum alanine aminotransferase, a marker of liver damage, and
HBV DNA levels are candidates for therapy. Treatment lasts from six months to a year,
depending on medication and genotype. Treatment duration when medication is taken by
mouth, however, is more variable and usually longer than one year. (CDC, 2014)
Although none of the available medications can clear the infection, they can stop the
virus from replicating, thus minimizing liver damage. As of 2018, there are eight
medications licensed for the treatment of hepatitis B infection in the United States. These
include antiviral medications lamivudine, adefovir, tenofovirdisoproxil,
tenofoviralafenamide, telbivudine, and entecavir, and the two immune system modulators
interferon alpha-2a and PEGylated interferon alpha-2a. In 2015 the World Health
Organization recommended tenofovir or entecavir as first-line agents. Those with current
cirrhosis are in most need of treatment, the use of interferon, which requires injections
daily or thrice weekly, has been supplanted by long-acting PEGylatedinterferon, which is
injected only once weekly. However, some individuals are much more likely to respond
than others, and this might be because of the genotype of the infecting virus or the
person's heredity. The treatment reduces viral replication in the liver, thereby reducing
the viral load (the amount of virus particles as measured in the blood). (CDC 2014)
2.2 Knowledge and attitude of medical students on hepatitis B risk and hepatitis B
vaccination
Generally, it is easy to assume that health care workers and medical students should
have adequate knowledge about diseases and other health conditions, by virtue of their
training and proximity to health facilities. Assessing people’s knowledge is a useful step
to assess the extent to which an individual or community is in a position to adopt a
disease-free behavior for this disease. Knowledge regarding HBV and safety precautions
is needed to minimize the health care settings acquired infections among health
personnel. Health care personnel should have complete knowledge of HBV infections,
importance of vaccinations are practice of simple hygienic measures apart from that of
specific protective measures (Othman et al., 2013) Knowledge of the clinician plays a
key role in prevention of spread of infection; people particularly health care workers who
lack adequate knowledge about HBV might ignore the importance of vaccination
(Othman et al., 2013). Unfortunately, researchers have also not shown enough interest in
evaluating the knowledge of medical students on hepatitis B virus infection or the
vaccine. Most previous studies in medical students in developing countries have revealed
inadequate knowledge of hepatitis B virus infection and inadequate practice of preventive
measures against the disease (Kesieme et al., 2016)
2.2.1 Prevention of hepatitis B
2.2.1.1 Hepatitis B vaccine
The HBV vaccine was introduced 1982 in the U.S. and in 1997 infant HBV vaccination
was introduced in Vietnam. It was part of a trial and was implemented in two cities;
Hanoi and Ho Chi Minh City (PATH, 2012) In 2003 a universal infant vaccination
programme was implemented in the whole country, but in 2006 still only 64% of the
new-borns got the birth-dose vaccine within 24 hours. If the birth-dose of hepatitis B
vaccine is given within the first 24-hours of birth, it prevents 80-90% of the virus
transmission between mother and child (PATH, 2012) Hepatitis B vaccine is a vaccine
that prevents hepatitis B. The first dose is recommended within 24 hours of birth with
either two or three more doses given after that. This includes those with poor immune
function such as from HIV/AIDS and those born premature. It is also recommended for
health-care workers to be vaccinated.In healthy people routine immunization results in
more than 95% of people being protected. (Socialstyrelsen, 2018) The hepatitis B vaccine
contains a protein (antigen) that stimulates the body to make protective antibodies.
Examples of hepatitis B vaccines available include hepatitis B vaccine-injection
(Engerix-B, Recombivax-HB). Three doses (given at 0, 1, and 6 months of age) are
necessary to assure protection (Edmunds et al, 2014) The HBV vaccine gives healthy
infants, children and adults a protective concentration of anti-HBs in 90-100% of the
cases if following the vaccination schedule properly. The vaccine is typically given in a
three-dose series. Persons who are immune-suppressed or over 40 years old are less
likely to develop protective concentrations (Shepard et al, 2016). It is not known if the
HBV vaccine gives lifelong protection against HBV and if boosters are necessary.
However, it is known that the protection is long lasting, at least 10-15 years, if the
vaccination schedule is followed correctly. Fever and pain at the injection site are the
most common side effects of the HBV vaccine. Allergic reactions have been reported but
are not common (Shepard et al, 2016). Hepatitis B vaccines are effective and safe. Up to
95% of vaccinated individuals form effective antibodies when they get the vaccine and
are protected from hepatitis B (Edmunds et al, 2014). In 16 healthcare workers, medical
students, high-risk public safety workers, dialysis patients, and sexual partners of infected
persons, a blood test for antibodies is recommended after vaccination to ensure that the
person produced antibodies. For the few who do not form antibodies, revaccination may
improve response, especially in infants. However, a small proportion of individuals will
never respond to hepatitis B vaccination (Liu et al., 2012).
2.2.1.3 Warnings/Precautions
Concerns related to adverse effects:
• Anaphylaxis/hypersensitivity reactions: Hypersensitivity and anaphylactic reactions can
occur; immediate treatment (including epinephrine 1 mg/ml) should be available. Use
with caution in patients with isolated immunoglobulin A deficiency or a history of
systemic hypersensitivity to human immunoglobulin’s.
• Infusion reactions: When administered IV, do not exceed recommended infusion rates;
may increase risk of adverse events. Patients should be monitored for adverse events
during and after the infusion.
• Thrombotic events: Thrombotic events have been reported with administration of
intravenous immune globulin; use with caution in patients of advanced age, with a
history of atherosclerosis or cardiovascular and/or thrombotic risk factors, patients with
impaired cardiac output, coagulation disorders, prolonged immobilization, or patients
with known/suspected hyperviscosity. Consider a baseline assessment of blood viscosity
in patients at risk for hyper viscosity (CDC, 2014)

2.3 Related study s

The study by (Taylor and co-workers , 2015) investigated knowledge and awareness of
hepatitis B among randomly selected Vietnamese adults living in the United States. 81%
of the 715 adults that participated in the study had heard of hepatitis B and 67% had been
tested for HBV. The knowledge of the infection was generally good, with about three-
quarters knowing the different ways of transmission but only 69% knew about infection
through unprotected sex. The (Ma and co-workers , 2017) Examined the knowledge of
HBV and liver cancer among 256 Vietnamese Americans with low socioeconomic status.
The results showed that the participants had general knowledge of HBV, but only 22%
knew that HBV can spread through unprotected sex. Many did not know that liver cancer
is preventable or that it is curable. Only a third of the participants knew about the vaccine
that protects against HBV. HBV infection and its effects, another study conducted among
first-year dental students among three dental colleges in Haryana showed that 84.9% of
the students were aware regarding the spread of HBV infection and only 23.7% of the
students had complete vaccination against hepatitis B. A study done in Taiwan reported
that 75.0% of the dental students had knowledge of hepatitis B infection, but had little
knowledge about vaccine dosage, transmission, prevention, and precautions of HBV
infection. Another study done on dental students in Maharashtra indicated that they had
good knowledge about HBV infection. A study done among Iranian dental students
showed that they had a relatively good level of knowledge about HBV infection and its
control practices. A study done in Pondicherry reported that 92.7% of the dental interns
were aware of HBV immunization. Another study done at the University of Dundee on
medical and dental students showed that 99.2% of students were aware of HBV
immunization. (Zhao et al., 2017) A study was carried out in China to investigate the
knowledge about HBV among 250 health professionals by handing out a questionnaire at
the “China national conference on the prevention and control of viral hepatitis”. The
results showed that even among highly educated health professionals the knowledge and
education was deficient. One-third of the respondents did not know that it is common for
chronic HBV infection to be asymptomatic or that it can lead to liver cancer, liver
cirrhosis and premature death. The authors believe that this increases the risk of health
professionals overlooking the significance of screening even those who are
asymptomatic, and vaccinating those who need it. (Chao et al., 2015)
Mohamed and co-workers (2012) 18 In (Slonim and co-workers, 2015) study carried out
in the U.S., 96 adolescents were individually interviewed and 17 063 adolescents and
young adults filled in a questionnaire. The participants were European-Americans,
African-Americans, multiracial, Native Americans, Asian and Pacific Islanders, and other
races. The study showed that the most common barrier to hepatitis B vaccine acceptance
was that the adolescents did not like getting shots (94%) and time-related barriers (50%),
as they had to come back two more times to the clinic to get the remaining doses of
vaccine. Almost two-thirds of the adolescents that were interviewed could not provide
any correct information before their clinic visit about hepatitis B.
 CHAPTER THREE
METHODOLOGY
3.0 Introduction

3.1 study area and period

This study will be conducted in Borama town west of Somaliland. Borama is a capital city of
Awdal region. the population of the borama is estimated to be 496628 inhabitants with a total
area of 14 km2 and the climate condition is semi area. Borma town has four sheekh the
income of people is depending on livestock, agriculture, trade, remittance and export. Also
borama has basic supply such as company of water supply and communication. The
populations are all Muslim. And they speak Somali language.

This study will be conducted in 2020, to assess the knowledge attitude and prevention regarding
hepatitis B among medical students in Borama city Somaliland 2020

This study will be conducted from julay up to august 2020

3.2 Study Design

Community based cross-sectional study design will be used, which is type of
observational study that analyzes data collected from population or representative subset.
At the specific point in time that is cross-sectional data. And it involves small sample
size, less cost, and short time.

3.3 source of population

The source population of this study will be all medical students at Horn University in
Borama city Somaliland.

3.4 Study Population

The Study population of this study will be all medical students at horn university Borama city
Somaliland.

3.5 Study Units

The study units of this study will be randomly selected all medical students at Horn university
Borama city Somaliland.
3.6 Eligibility criteria

3.6.1 Inclusion criteria

3.6.2 Exclusion criteria

3.7 Sample size determination

The required sample size for this study was determined by single population proportion
formula with the following assumption:

The risk of contracting HBV by medical students is four times greater than that of the general
adult population who do not work or practice in healthcare institutions. It is also a well-
established fact that an unvaccinated individual stands the risk of 6% to 30% to acquire the
infection on exposure to HBV contaminated blood or body fluids.

Where:

n=requiredsampledsize
Z = standard transformation, α is type 1 error value out of 95% confidence interval
P= 30%

d = margin of error (5%)

2
Zα
n=
( ) p ( 1−q )
2 =n=
( 1.96 x 1.96 )( 0.3 ) (0.7) 0.806736
(0.05)2
=
0.0025
= 323
2
w

3.8 Sampling Procedure

The sapling procedure of this study was purposive sampling and simple random
sampling technique this is probability sample in which the researcher uses (lottery
method) the subset of individual is chosen from larger set, each individual is chosen
randomly and entirely by chance. To select the key respondents

3.9 Data collection procedures

A structured written questionnaire will be administered by the data collectors. This questionnaire will
be written in English and then translated Somali, the local language. Hepatitis B virus infection will
be interviewed on their knowledge attitude and prevention regarding hepatitis B among medical
students.

3.10 pretesting
15% of the Questionnaires will be pretested for purposes of comprehension, readability, and
easiness of administration. After piloting, if we see any misunderstand since according to
response we will correct

3.11 data quality

Data quality will be assured by using different approach. First the questioner will be
prepared in English form then translated in local language Somalia. Data collect will be make
regular supervision and follow up in supervisor, in order wards regular check up
completeness and consistency of the data will made on daily bias

3.12. Data process analysis

The data analysis of this study will be used by SPSS version 23.. The descriptive statistics of
the study will be carried to measure the relative frequency, percentage, pie chart, table, and
figures. The data will be presented by pie chart, bar chart, histogram, table, and figures.

3.13 Study variables

3.13.1 Dependent variables

Hepatitis B virus infection

3.13.2 Independent variables

Knowledge attitude prevention and socio-demographic characteristic hepatitis B among
medical students.

3.14 Ethical Considerations

To ensure confidentiality of the information provided by the respondents and to ascertain

the practice of ethics in this study, the author’s knowledge is quoted in this study and the
author of the standardized instrument through citations and referencing. Present the
findings in a generalized manner.

3.15. Plan for dissemination

The findings will be presented to the Horn International University scientific and it will be
also be communicated with policy makers, library, websites,.
 Work plan

Table 1:-Work plan for identifying knowledge attitude and prevention regarding hepatitis B
among medical students at Horn University in Borama Somaliland.

No Duration Activity
1 1 July 2021 Approved title
2 4 July 2021 Chapter one
3 25 July 2021 Chapter two
4 16 July 2021 Chapter three