Research about the people who have bad attitude and knowledge with those who have hepatitis.pdf

In this research, I have explained different topics including the bad attitude and knowledge about a person who have hepatitis.

This research is driven on the misconduct with those who have hepatitis.

1. KAP STUDY ON HEPATITIS IN INSTITUTE OF HEALTH OF SCIENCE
NANGARHAR






Descriptive Study


BY Dr. Mohammad Asif

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Thesis Submitted to the Faculty of Abasyn University, Peshawar, Requirements for the
Degree of MMSPH (master of management science and master of public health) 6
th

Semester.

















DEPARTMENT OF MANAGEMENT SCIENCES
ABASYN UNIVERSITY PESHAWAR
2017 – 2018

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Dedication







I dedicated my research work to all respected
doctors

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ACKNOWLEDGMENTS


I respectfully present my thanks to Almighty ALLAH, the supreme and the omniscient,
whose blessing and mercy enabled me to successfully complete my this research study. I
also offer all respects from the deepest core of my heart to the HOLY PROPHET
MOHAMMAD -UR-RASULULLAH, who is a forever source of guidance and
knowledge for all of humanity in the world.
Special thanks to my supervisor Muhammad Atif, master of public health, Abasyn
University Peshawar, for his professional and technical support in completing my
MMSPH studies successfully. His interest in my studies enabled me to perform my
research work with great keenness and affection. His valuable suggestions, honest
guidance, fruitful tips and compassionate character encouraging nature and Islamic
personality will lead me throughout my life to an accurate direction ALLAH blesses
him.
I am also very thankful to Mr. Shahid Rashid, assistant professor Coordinator of
Management Science Departments, Abasyn University Peshawar, for her guidance
throughout my studies. I will always appreciate his encouraging counsel, leading skills
and sincere advices. He will always remain an ideal personality for me throughout my
educational career.




Dr. Mohammad Asif

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Abstract

Background: The study was conducted in the capital city of Jalalabad, Nangarhar
province, Afghanistan. Objectives: To know the knowledge, attitude and practice
regarding Hepatitis in the young students of institute of health sciences, Nangarhar
Afghanistan. Methods: The study was a descriptive KAP study, based on structured
questionnaire by carrying out primary survey regarding the same. The study was
carried out on June 2017 to May 2018 and the questionnaires were retrieved on the
same day daily filled in by the candidates. SPSS 16.0 software was used for data
analysis. The total sample size was 100. Results: the study was a descriptive study
carried out on a descriptive biometric qualitative data. Of the 100 respondents who
were questioned along the variables of yes, no, I don’t know, 59.63 % had knowledge
about Hepatitis, 40.34 % (in this estimation 27% responded no and 13.34% answered I
don’t know).

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Conclusions KAP: From our study we can conclude that there is considerable
knowledge and attitude regarding Hepatitis with some percentage of the study
population involved in high risk behavior. However, much work needs to be done
regarding the awareness in term of knowledge attitude and practice of Hepatitis.

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Acronyms and Abbreviations list



ELISA Enzyme Linked Immune Sorbent Assay
HAART Highly active antiretroviral therapy
PCR Polymerize chine reaction
IDUs Injecting Drug Users
KAP Knowledge, Attitude and Practice
MOH Ministry of Health
MPH Master of Public Health
MTCT Mother-to-child transmission
N Number of individuals who responded (sample size).
NGOs Non-Governmental Organizations
STD Sexually Transmitted Diseases
UNESCO United Nations Educational, Scientific and Cultural
Organization
UNICEF United Nations Children’s Emergency Fund
US United States of America
WHO World Health Organization

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Table of Contents
Acknowledgements………………………………………………… ……………………… .4
Abstract ..................................................................................................................................... 5
Acronyms and Abbreviations list ........................................................................................... 6
Table of contents ..................................................................................................................... 7
Chapter 1 11
interoduction 11
Difinition 11
Hepatitis A 11
Agent 12
Resevoir of infection .............................................................................................................. 12
Age:.......................................................................................................................................... 12
Immunity 12
Modes of transmission 12
Parenteral Rout 13
Incabation period 13
Clinical spectrum 13
out comes of infection with hepatitis A virus....................................................................... 13
Diagnosis ................................................................................................................................. 13
prevention and containment 14
Control of susceptible poplation ......................................................................................... 14
Human immunoglobulin 14
Vaccines 15
Hepatitis B: 15
Epidemiological determinants Agent factor 16
Resrvoir of infection 16
Infective mateial 16
period of communicability 16
Host factors 16
Age 16
High risk groups 16
Source 17
Anti-HBC 17
HBV-DNA 17
Modes of transmission 18
prenatal transmission 18
sexual transmission 18
ther routes 18
Incobation pariod 18
Clinical picture 18
Sources 18

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common serological patterns in hepatitis B virus infection and their interpretation
(Table 2) 19
Prevention and containment 19
Hepatitis B vaccine 19
Hepatitis B immunoglobulin (HBIG) 21
Passive active immunization 21
Other measures 21
Hepatitis C 21
Hepatitis E 23
Hepatitis D 23
Hepatitis G 24
Table 3 24
Chapter 2 26
Literture revies 26
Chapter 3 26
Methodology 26
Hypotisis 27
study design 17
sample size 27
sample collection 27
Data collection 27
Chapter 4 29
Ananlysis 29
Figure 4 30
Table 5 Error! Bookmark not defined.
Table 6:Do you know hepatitis 32
Table 7: have you ever heard . wachad / read about hepatitis 33
Table8: Hepatitis is a big problem as media suggested 34
Figure 9: is there any vaccines for hepatitis 35
Table 10: can hepatitis be cured by medicine 36
Figure 11: that can happen to all people 37
Table 12: hepatitis educational program is necessary for students 38
Table 13: healthy looking transmit hepatitis 39
Table 14:hepatitis can be spread by social kissing hepatitis infected personts 40
Table 15: hepatitis can be spread by insect or mosquito bite 41
Table 16: hepatitis infectiu mothers to there now borne 42
Table 17:hepatitis can spread by breast feeding 43
Table 18:hepatitis can be spread by transfusion of blood donted by hepatitis infected
44
Table 19:hepatitis can be spread by piercing of the ear nose and other part
Error! Bookmark not defined.
Table 20:hepatitis can be spread by sharing rezors with hepatitis infected person 46

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Table 21:hepatitis can be spread by using same drinking gloss or eating plate 47
Table 22:hepatitis can not be spread by being fuithful to infected person 48
Table 23:can you be come infected by having unprotected sex with a person who is
infected with hepatitis 49
Table 24:polygamy (malti marriage ) can increases the risk of hepatitis infection
Error! Bookmark not defined.
Table25:using of condum can protact hepatitisinfective Error! Bookmark not
defined.
Table 26: Do know casual Agent of hepatitis Error! Bookmark not defined.
Table 27:would you be willing to stay with studants who is hepatitis positive
Error! Bookmark not defined.
Table 28:would you be willing to use the same toilat with studants who is hepatitis
positive Error! Bookmark not defined.
Table 29: would you be to eat food of a company prepared by worker who is hepatitis
positive Error! Bookmark not defined.
Table 30:would you be willing to swim in a pool with hepatitis positive person
Error! Bookmark not defined.
table 31:would you be willing to share a room with same one living hepatitis positive
Error! Bookmark not defined.
Table 32:would you be willing to receive medical treatmant from a health care
worker who is hepatitis positive Error! Bookmark not defined.
Table 33:would you be willing to utilize the services of a barber or ahair dresser who
is hepatitis positive 59
Table 34:Do you agree with vonlunteer testing 60
Table 35:Do you agree with screening befor marriage 61
Table 36:Do you agree with isolation of people living with hepatitis positive 62
Table 37:All studants should be hepatitis tested 63
Table 38:Do you agree hepatitis positive patients care 64
Figure 39 65
Chapter 5 : Discassions :66
Chapter 6 : Conclusions : 67
Recomandetion 67
References 67
Appendix One: Questionnaire .............................................................................................. 67
Questionnaire ......................................................................................................................... 67

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Chapter 1: Introduction
Definition:
Viral hepatitis may be defined as infection of the liver caused by any half dozen viruses.
Twenty yours ago A virus (HAV) and hepatitis B virus (HBV) were the only known a
etiological agents of viral hepatitis. today in addition to HAV and HBV hepatitis viruses
C D E and G have also been identified and are recognized as a etiological agents of viral
hepatitis .it is known that many other viruses may be implicated in hepatitis such as
cytomegalo-virus, Epstein –Barr virus, yellow fever virus and rubella virus .viruses of
herpes simplex, varicella and adenoviruses can also cause severe hepatitis in immune-
compromised individuals, but are rare.
Hepatitis A:
Hepatitis A (formerly known as “infectious” hepatitis or epidemic jaundice) is an acute
Infectious disease caused by hepatitis A virus (HAV).the disease is heralded by non
specific symptoms such as fever, chills, headache, fatigue, generalized weakness and
aches and pains. Followed the anorexia, nausea, vomiting, dark urine and jaundice. The
Disease spectrum is characterized by the occurrence of numerous subclinical or
asymptomatic cases .the disease is benign with complete recovery in several weeks .the
case fatality rate of icteric cases is less than 0.1 percent, usually from acute liver failure
and mainly affects older adults although the disease has, in general low mortality
(0.1%) patients may be incapacitated for many weeks.
Being entero virus inaction like poliomyelitis, hepatitis A is endemic in most developing
countries, with frequent out bursts of minor or major out breaks. The exact incidence of
the disease is difficult to estimate because of the high proportion of asymptomatic cases.
According to WHO about 10-50 persons per 100,000 are affected annually. Evidence
from several developed countries indicates that the incidence of hepatitis A is declining.
Hepatitis A virus infection is very common in all the countries of SEAR. Poor standard
hygiene and sanitation facilitate the spread of HAV in high endemic areas. The level of
HAV circulation in the population is extremely high. Sero-epidemiological studies
carried out in India Bangladesh, Bhutan and Nepal demonstrated that 85-95 percent of
children have been infected and are immune to HAV infection by 10 years of age.
However, only a small number of infected children develop symptoms of disease. Study
of the aetiology of sporadic hepatitis case conducted in these countries demonstrated
that HAV infection is responsible for approximated 10 to 25 percent of the total cases of
hepatitis in children.
Outbreak of HAV infection that have been well documented, mostly in urban settings.
Are associated with unsafe drinking water and food. For practical purposes, the world
can be divided into areas of low, intermediate and high endemicity, although there may
be regional differences in endemicity within a country. In areas of low endemicity the
disease occurs mainly in adolescents and adult. In areas of intermediate endemicity,

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many individuals escape childhood infection, but are exposed later in life when clinical
hepatitis occurs more frequently .in these areas, cases occur in lathe childhood and
early adulthood .in areas of high endemicity ,where the lifetime risk of infection is
greater than 90 per cent, most infections occur in early childhood and are
asymptomatic. Thus clinically apparent hepatitis A is rarely seen in these areas.
Countries in transition from developing to developed economies gradually move from
high endemicity to intermediate endomicity, and HAV is likely to become more serious
problem in these areas
The exact incidence of HAV in India is not known. The Indian literature is replete with
numerous reports of sporadic and epidemic occurrence of this disease in various cities
residential colonies and campuses .epidemics of hepatitis A often evolve slowly. Involve
wide geographic of areas and last many months, but common source epidemic (e.g.,
faecal contamination of drinking water) may evolve explosively.
Epidemiological determinants
Agent factors:
Agent: the causative agent. The hepatitis A virus is an enterovirus (type 72) of the
picornaviridae family it multiplies only in hepatocytes. Faucal shedding of the virus is at
its highest during the later part of the incubation period and early acute phase of illness.
Only one serotype is known.
Resistance: the virus is fairly resistant to heat and chemicals. It has been shown to
survive more than 10 weeks in well water. It with stands heating to 60 deg c for one
hour and is not affected by chlorine in doses usually employed for chlorination
.formalin is stated to be an effective disinfectant. The virus is inactivated by ultraviolet
rays and by boiling for 5 minutes or autoclaving .in short the virus survives for long
periods under variable conditions and resists many procedures that eliminate or
inactivate most bacteria agents.
Reservoir of infection: the human cases are the only reservoir of infection .the cases
range from asymptomatic infections to severe ones. Asymptomatic (anicteric) infections
are especially common in children .these cases play an important role in maintaining the
chain of transmission in the community .there is no evidence of a chronic carrier state.
Period of infectivity: the risk of transmitting HAV is greatest from 2 weeks before to 1
week after the onset of jaundice .infectivity falls rapidly with the onset of jaundice.
Infective material: mainly man’s faeces, blood, serum and other fluids are infective
during the brief stage of viraemia.
Virus excretion: HAV is excreted in the faeces for about 2 weeks before the onset of
jaundice and for up to 2 weeks thereafter. The virus may also be excreted in urine
Host factors:
Age: infection with HAV is more frequent among children than in adults.
however,people from all ages may be infected if susceptible. In young children,
infections tend to be mild or subclinical .the clinical severity increased with age .the
ratio of anicteric to icteric cases in adults is about 1:3: in children, it may be as high as
12:1. However, faecal excretion of HAV antigen and RNA persists longer in the young
than in adults. In India, by the age of 10 yours, 90 per cent of healthy persons have
serological evidence of HAV infection.
SEX: both sexes are equally susceptible.
IMMUNITY : immunity after attack probably lasts for life, second attacks have been
reported in about 5 per cent of patients most people in endemic areas acquire immunity
through subclinical infection .the IgM antibody appears early in the illness and persists
for over 90 days . IgG appears more slowly and persists for many years.

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Environmental factors:
Cases may occur throughout the year .in India the disease tends to be associated with
periods of heavy rainfall poor sanitation and overcrowding favor the spread of
infection, giving rise to water- borne and food –borne epidemics. Paradoxically, when
standards of hygiene and sanitation are improve, morbidity from infection with enteric
viruses .this is what happened with poliomyelitis, and is now being seen with hepatitis.
Modes of transmission;
Faeca-oral route: this is the major route of transmission. it may occur by direct (person-
to-person )contact or indirectly by way of contaminated water ,food or milk .water –
borne transmission, is not a major factor in developed countries ,where food –borne
outbreaks are becoming more frequent. for example ,consumption of raw or
inadequately cooked shellfish cultivated in sewage polluted water is associated with
epidemic outbreaks of hepatitis A direct transmission comprises an array of routes such
as contaminated hands or objects such as eating utensils .direct infection occurs readily
under conditions of poor sanitation and overcrowding .
PARENTERAL ROUTE:
Hepatitis A is rarely, if ever transmitted by the penetration route (i,e,by blood and
blood products or by skin penetration through contaminated needles ) this may occur
during the stage of viraemia. This mode of transmission is of minor importance.
SEXUAL TRANSMISSION : As a sexually transmitted infection hepatitis A may occur
mainly among homosexual men because of oral-contact.
Incubation period:
10 to 50 days (usually 25 to 30 days) the length of the incubation period is proportional
to the dose of the virus ingested.
CLINICAL SPECTRUM:
The onset of jaundice is often preceded by gastrointestinal symptoms such as nausea,
vomiting .anorexia and mild fever .jaundice may appear within a few days of the
prodromal period, but anicteric hepatitis is more common. The outcome of infection
with HAV is as shown in Table 1

Outcomes of infection with hepatitis A virus





Outcome children Adults
In apparent (sub-clinical)infection 80-95 % 10-25%
Enteric disease 5-20 % 75-90 %
Complete recovery >98% >98 %
Chronic disease none none
Mortality rate 0.1% 0.3-2.1%

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Diagnosis:
Test for abnormal liver function ,such as serum alanine aminotransferase (ALT)and bilirubin
A specific laboratory diagnosis of hepatitis A by viral antigens in the faeces,bile and blood.
HVA is detected in the stool from about 2 weeks prior to the onset of jaundice ,up to 2 weeks
I HVafter .Anti HVA appear in the IgM fraction during the acute phase ,peaking about 2
weeks after elevation of liver enzymes .Anti HVA IgM usually declines to non-detectale
levels within 3-6 months .Anti.HVA IgM appear soon after the onset of disease and persists
for decades. Thus detected of IgM. specific anti HVA in the blood of an acutely infected
patient confirms the diagnosis of hepatitis A. ELISA is the method of choice for measuring
HVA antibodies .
Prevention and containment:
A .control of reservoir
Control of reservoir is difficult because of the following factors. faecal shedding of the
virus is at its height during the incubation period and early phase of illness. The
occurrence of large number of subclinical cases. Abcence of specific treatment and low
scoio- economic profile of the population usually involved. Stricte isolation of cases is
not useful control measure because of and however attention should be paid to the usual
control measures such as notification, complete bed rest and disinfection of faeces and
fomites. The use of 0.5 per cent sodium hypochlorite has been strongly recommended as
an effective disinfectant.
Control of transmission:
The best means of reducing the spread of infection is by promoting simple measures of
personal and community hygiene .e.g. hand washing before eating and after toilet. The
sanitary
Disposal of excreta which will prevent contamination of water, food and milk. A
question is often asked how much chlorine is needed to inactivate the virus .studies
indicated that 1 mg /l of freer residual chlorine can cause destruction of the virus in 30
minutes at pH values of 8.5 or less .the water treatment and distribution system should
be improved. During epidemics ,boiled water should be advocated for drinking
purposes .boiled water should be advocated for drinking purposes .several countries of
the world have achieved control of water –borne HAV infection .other control measures
include proper autoclaving of syringes ,needles and other equipment .if all these
measures are properly implemented ,a substantial reduction of HAV infection can be
expected .
Control of susceptible population:
Human immunoglobulin ; A well established procedure is the use of normal human
immunoglobulin prepared from pooled plasma of healthy donors (gamma globulin) to
induce passive immunity. It is recommended for susceptible persons travelling to highly
endemic areas. Close personal contacts of patients with HAV for the control of
outbreaks in institution doses of immunoglobulin recommended by WHO gamma
globulin given before exposure to the virus or early during the incubation period, will
prevent but does not always prevent infection and the excretion of the virus .in apparent
and subclinical infection may be develop. this May be followed by passive active
immunity .the efficacy of passive immunization depends upon the presence of hepatitis
A antibody in the immunoglobulin and on dosage and time of administration relative to
exposure when given in proper dosage within 1 to 2 weeks of exposure .it prevents
illness in 80 to 90 per cent of those exposed .if given after onset of symptoms ,no benefit
is likely to result .the value of immunoglobulin in controlling outbreaks of infection in

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place such as nursery schools has been demonstrated .however ,a WHO expert
committee. Has expressed the view that the use of immunoglobulin on a very large scale
is unwise for three reasons .the individual with subclinical infection may still
disseminate the virus in the general community .the practice appears to be wasteful, and
,repeated injection of immunoglobulin may be undesirable in healthy children .the large
–scale routine use of immunoglobulin as a preventive measure for hepatitis A among
school-age children ,or other special populations, has not gained widespread acceptance
.
Vaccines ; several inactivated or live attenuated vaccines against hepatitis A have been
developed ,but only 4 inactivated hepatitis A vaccines are currently available
internationally. All 4 vaccines are similar in terms of efficacy and side effect profile. The
vaccines are given parent rally, as a 2-dose series 6-18 months apart. The dose of
vaccines, vaccination schedule age for which the vaccines is licensed, varies from
manufacturer to manufacturer. No vaccines are licensed for children aged less than one
year. A combination vaccines containing inactivated hepatitis A and recombinant
hepatitis B vaccines has been licensed since 1996 for use in children aged 1 year or older
in several countries .the combination vaccines is given as 3 dose series using 0,1,6
months schedule.
Hepatitis B:
Hepatitis B (formerly known as “serum” hepatitis) is an acute systemic infection with
major pathology in the liver caused by hepatitis B virus (HBV) and transmitted usually
by the parenteral route. It is clinically characterized by a tendency to a long incubation
period (6 weeks to 6 months) and a protracted illness with a variety of outcome. Usually
it is an acute self-limiting infection, which may be either subclinical or symptomatic. In
approximately 5 to 15 per cent of cases, HAV infection fails to resolve and the affected
individual then become persistent carriers liver disease including chronic active
hepatitis and hepatocellular carcinoma there is also evidence of a close association
between hepatitis B and primary liver cancer. Hepatitis B virus can form a dangerous
alliance with delta virus and produce a new form of virulent hepatitis which is
considered to be widespread threat for much of the world.
Problem statement world:
Hepatitis B is endemic throughout the world, especially in tropical and developing
countries and also in some regions of Europe .its prevalence varies from country to
country and depends upon a complex mix of behavioral environmental and host factors.
In general, it is lowest in countries or areas with high standards of living the HBV
infection is a global problem, with 66% of all the world’s population living in areas
where there are high levels of infection .
More than 2 billion people worldwide have evidence of past or current HBV infection
and 350 million are chronic carrier of the virus, which is harboured in the liver, and
causes an estimated 600,000 deaths from cirrhosis of liver and hepatocellular
carcinoma. The virus causes 60-80 % of all primary liver cancer. Between 5% and 10%
of adults and upto 90% of infants infected with HBV become carriers. Among these
25%, in the long term, develop serious liver disease .hepatitis B is endemic in china and
other parts of asia. in these regions 8-10% of the adult population are chronically
infected .in the middle east and Indian sub continent, an estimated 2-5 % of the general
population is chronically infected .in western Europe and north America less than 1%
population is infected .based on the different HBs Ag carrier rates, countries can be
divided into three categories: high endemicity >8% intermediate > 2-8 % and low
endemicity < 2% countries of the region can be divided into three epidemiological

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patterns. The type 1 occurs in Nepal and srilanka and is characterized by a low
HBsAg.carrier rate of 0.9 to 1.0 %.the second pattern (type 2) can be found in Bhutan,
india ,Indonesia and Maldives where carrier rate is high in the general population (5 to
7%) in india alone there are an estimated 43 to 45 million HBsAg carrier and ,among
them 10 to 12 milion also have HBsAg.type 3 is observed in Bangladesh ,DPR korea
,Myanmar and Thailand ,where the carrier rate is very high and ranges from 9% to 12
% transmission of HBV infection by blood transfusion and in other medical
intervention in both modern and traditional health practices is also common in the
region. In india ,the carrier rate of HbsAg in hospital staff has been found to be
higher(10.87%) than in voluntary blood donors (6%) and in the general population
(5%) in india there are only 806 licensed blood banks and the incidence of post
transfusion hepatitis in multiple–tranfused patient is as high as 18 to 30 %
Epidemiological determinants Agent factors:
Agent: hepatitis B virus was discovered by Blumberg in 1963. Efforts to grow this virus
have been so for unsuccessful HBV is a complex ,42 nm double – shelled DNA virus ,
originally known as the “Dane particale” it replicates in the liver cells HBV occurs in
three morphological forms in the serum of a patient: small spherical particles with an
average diameter of 22-nm. These particles are antigenic and stimulate production of
surface antibodies .the purified 22-nm particles are used in the preparation of hepatitis
B vaccine: tubules of varying length and diameter and the Dane particle which
corresponds morphological to hepatitis B virus. A person who is serologically positive
for the surface antigen is circulating all morphological forms, of which 22 nm particles
constitute the bulk. Of the three morphological forms, only the Dane particle is
considered infectious, the other circulating morphological forms are not infectious.
Reservoir of infection:
Man is the only reservoir of infection which can be spread either from carriers or from
cases .the continued survival of infection is due to large number of individuals who are
carriers of the virus. The persistent carrier state has been defined as the presence of
HBs Ag (with or wiyhout concurrent HBs Ag) for more than 6 months. Cases may range
from inapparent to symptomatic cases.
Infective material:
Contaminated blood is the main source of infection, although the virus has been in body
secretions such as saliva, vaginal secretions and semen of infected persons.
Resistance:
The virus is quite stable and capable of surviving for at least 7 days on environmental
surfaces .it can be readily destroyed by sodium hypoclorite, as is by heat sterilization in
an autoclave for 30 to 60 minutes.
Period of communicability:
The virus is present in the blood during the incubation period (for a month before
jaundice) and acute phase of the disease. Period of communicability is usually several
months (occasionally years in chronic carriers) or until disappearance of HBs Ag and
appearance.
Host factors:
Age: The outcomes of HBV infection are age –dependent. Acute hepatitis B occurs in
approximately 1% of perinatal ,10% of early childhood (1-5 years of age) and 30 % of
late (>5 years age )HBV infections. Mortality from fulminant hepatitis B is
approximately 70 % the development of chronic HBV infection is inversely related to
age and occurs in approximately 89-90% of persons infected prenatally in 30 % infected
in early childhood (less than 6 years of age) and in 5% infected after 6 years of age.

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High risk groups:
Certain groups carry higher risks. The annual incidence of HBV infection in surgeons is
estimated to be 50 times greater than that in the general population and is more than
twice that of other physicians. Other high risk groups comprise recipients of blood
transfusions, health care and laboratory personnel, homosexuals, prostitutes,
percutaneous, drugs abusers, infants, of HBV carrier mothers ,recipients of solid organ
transplants and patients who are immune-compromised serological screening and
vaccination of high risk groups is highly recommended.
Hepatitis B and HIV infection:
It is estimated that 10 % of the 40 million people infected with HIV worldwide are
coinfected with with HBV. Alghough HBV infection appears to have a minimal effect on
the progression of HIV. Positive people due to HBV coinfection both before and after
commencement of highly active anti-retroviral therapy.
Humoral and cellular responses:
Hepatitis B virus has three distinct antigens –a surface antigens also known as
“Australia antigen”(HBsAg) a core antigen (Anti HBc) and an “e”antigen(HBeAg)they
stimulate the production of corresponding antibodies e.g. Surface antibody (anti-HBs)
core antibody (anti-HBc)and “e”antibody (anti-HBe) these antibodies and their
antigens constitute very useful markers of HBV infection . Patients with HBV infection
are expected to have one or more HBV markers. The course of a typical acute hepatitis
is outlined in
HBs Ag; the appearance of HBs Ag is the first evidence of infection (in 30-60 days)
appearing before biochemical evidence of live disease, and persists throughout the
illness. Persistence of HBs Ag after the acute illness may be associated with clinical and
laboratory evidence of typical sequence of HBV serological marker appearance
Source:
Chronic hepatitis for variable period of time. The detection of HBsAg establishes
infection with HBV and implies infectivity.
Anti-HBs:
Anti-HBs specific antibody to HBs Ag (anti-HBs) appears in most individuals after
clearance of HBs Ag and after successful vaccination against hepatitis B disappearance
of HBsAg and the appearance of anti-HBs signals recovery from HBV infection, non
infectivity and immunity.
Anti-HBc:
IgM anti-HBc appears shortly after HBs Ag is detected. (HBc Ag alone does not appear
in serum) its presence in the setting of acute hepatitis indicates a diagnosis of acute
hepatitis B and it fills the serologic gap in patients who have cleared HBsAg but do not
yet have patients who have or longer. IgM anti-HBc may also reappear during flares of
previously inactive chronic hepatitis B IgM anti-HBc also appears during acute
hepatitis B but persists indefinitely whether the patient recovers (with the appearance of
anti-HBs.HBs Ag) in asymptomatic blood donors, an isolated anti-HBc with no other
positive HBV serologic results may represent a falsely positive result or latent infection
in which HBV DNA is detectable only by polymerase chain reaction testing.
HBeAg:
HbeAg is a soluble protein found only in HBsAg positive serum .it is a secretory form of
HBcAg appearing during the incubation period shortly after the detection of
HBsAg.HbeAg indicates viral replication and infectivety persistence of HBeAg in serum
beyond 3 months indicates an increased likelihood of chronic hepatitis B its

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disappearance is often followed by the appearance of anti-HBe signifying diminished
viral replication and decreased infectivity.
HBV DNA:
The presence of HBV DNA in serum generally parallels the presence of HBeAg,
although HBV DNA is a more sensitive and precise marker of viral replication and
infectivity .very low levels of HBV DNA detectable only by polymerase chain reaction
testing may persist in serum and liver long after a patient has recovered from acute
hepatitis B but the HBV DNA in serum is bound to IgG and is rarely infectiouas in
some patients with chronic hepatitis B HBV DNA is present at high levels without
HBeAg in infected hepatocytes. This pre –core mutant” appears during the course of
chronic wild –type HBV infection presumably as a result of immune pressure. When
additional mutation in the core gene is present, the pre-core mutant enhances the
severity of HBV and increases the risk of cirrhosis.
Modes of transmission:
Parenteral route: hepatitis B is essentially a blood –borne infection. It is transmitted by
infected blood and blood products through transfusions, dialysis, contaminated syringes
and needles pricks of skin, handling of infected blood, accidental inoculation of minute
quantities of blood such as may occur during surgical and dental procedures
,immunization traditional tattooing, ear piercing, nose piercing, ritual circumcision,
acupuncture etc. Accidental percutaneous inculcations by shared razor and tooth
brushes have been implicated as occasional causes of hepatitis B.
Prenatal transmission:
Spread of infection from HBV carrier mother to their babies appears to be an
important factor for the high prevalence of HBV infection in some regions, particularly
china and SE Asia. The risk of infection varies from country to country and unless
vaccinated at birth, the majority of children born to mother who are HBeAg-positive
become chronically infected. The mechanism of perinatal infection is uncertain.
although HBV can infect the foetus in utero, this rarely happens and most infections
appear to occur at birth, as a result of a leak of maternal blood into the baby’s
circulation or ingestion or accidental inoculation of blood infection of the baby is
usually anicteric and is recognized by the appearance of surface antigen between 60-120
days after birth.
Sexual transmission:
There is ample evidence for the spread o f infection by intimate contact or by sexual
route. The sexually promisuous, particularly male homosexuals are at very high risk of
infection with hepatitis B.
Other routes:
Transmission from child-to child .often called horizontal transmission is responsible for
a majority of HBV infections and carriers in parts of the world other than Asia. The
researchers believe that the spread occurs through physical contact between children
with skin conditions such as impetigo and scabies or with cute or grazes. Often
transmission occurs when children play together or share the same bed in short,
transmission occurs in a wide variety of epidemiological settings. It can spread either
from carriers or from people with no apparent infection or during the incubation
period, illness or early convalescence.
Incubation period:
30 to 180 days lower doses of the virus result often in longer incubation period. The
average incubation period is about 75 days.
Clinical picture:

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19

The symptoms and manifestation of hepatitis B are similar to those of the other types of
viral hepatitis .but the picture is complicated by the carrier state and by chronic liver
disease, which may follow the infection. Chronic liver disease may be severe, and may
progress to primary liver cancer which, in some parts of the world, is one of the
commonest human cancer,
Source: there are three distinct antigen antibody systems that relate to HBV infection
and a variety of circulating makers that are useful in diagnosis. Interpretation of
common serological patterns is as shown in Table 2



Common serologic patterns in hepatitis B virus infection and their interpretation
HBs Ag Anti-HBs Anti-HBc HBe Ag Anti-HBe interpretation
+ _ IgM + _ Acute hepatitis B
+ _ IgG + _ chr.H.B with active viral replication
+ _ IgG _ + chronic H.B with low viral replication
+ + IgG +or_ +or_ chr,h,B with heterotypic anti-HBs10%
_ _ IgG +or_ _ Acute hepatitis B
_ + IgM _ +or_ Recovery from hepatitis B(immunity)
_ + IgG _ _ Vaccination (immunity)
_ _ - false-positive less commonly infection
IgG _ _ in remote past


Low levels IgM anti-HBc may also be detected
Prevention and containment:
Since there is no specific treatment. Prevention has been the major aim in managing
viral hepatitis B. The following measures are available.
Hepatitis B vaccine:
Plasma derived vaccine: this is based on the surface antigen (HBsAg) which is harvested
and purified from the plasma of human carriers of hepatitis B viral vaccine for
intramuscular injection. Each 1.0 ml dose of the vaccine contains 20 micrograms of
hepatitis surface antigen formulated in alum adjuvant.
Recombinant HBV vaccine: the recombinant hepatitis B vaccine was introduced in 1986
and has gradually replaced the plasma –derived hepatitis B vaccine. The active
substance in recombinant hepatitis B vaccine is HbsAg that has been produced in yeast
or mammalian cells into which the HBsAg gene (or HbsAg/pre HBsAg genes) has been
inserted using plasmids .the transformed cells are grown in large vessels and the
expressed HBsAgself-assembles into spherical particles that expose the highly
immunogenic a determinant. The recombinant particles differ from natural ones only in
the glycosylation of the HbsAg, following thorough purification from host-cell
components ,alum (and in certain formulations, thiomersal) is added A new
recombinant hepatitis B vaccine that is intended for adult patients with renal
insufficiency uses alum and lipid a as adjuvant.
Field trials have shown that this genetically engineered vaccine is as immunogenic, safe
and effective as the plasma –derived vaccine and is more cost –effective than the plasma

20. 20



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derived vaccine .the fact that this vaccine does not depend on the scarce plasma
resource is an added advantage .hepatitis B vaccine is available as monovalent
formulation, or in fixed combination with other vaccines, including DPT,HiP, hepatitis
A and inactivated polio. The immune response and safety of this combination of
vaccines are comparable to those observed when the vaccine is administered separately.
When immunizing against HBV at birth, only monvalent hepatitis B vaccine should be
used. Internationally marketed hepatitis B vaccines are considered immunologically
comparable and can be used interchangeably.
The dose for adult is 10-20 micrograms initially (depending on the formulation) and
again at 1 and 6 months. Children under 10 years of age should be given half of the
adult dose at the same time intervals. For greatest reliability of absorption the deltoid
muscle is preferred for injection as gluteal injection often results in deposition of
vaccine in fat rather than muscle, with fewer serologic conversion. For infants and
children under 2 years. Anterolateral aspect of thigh is used as vaccination site.
Intradermal administration is not recommended because the immune response is less
reliable particularly in children. The hepatitis B can be given safely together with BCG
Vaccine. However, the vaccines should be given at different sites there are multiple
options for incorporation the hepatitis B vaccine into national immunization and
programme consideration .the recommended schedule for vaccination can be divided
into those that include a birth dose and those that do not. Schedules with a birth –dose
call for first dose at birth, followed by a second dose and third dose at the time of the
first and third dose of DPT vaccination respectively. Alternatively, a four-dose schedule
may be used where the dose at birth is followed by three additional doses these doses
may be given either as monovalent vaccine or as a combination (e.g with DPT and/or
Hib) following the schedules commonly used for these vaccines. The minimum
recommended interval between the doses is four weeks longer dose intervals may
increase the final anti-HBs titers but not the sero-conversion rates .these schedules will
prevent most perinatally acquired infection. In countries where a high proportion of
HBV infection is acquired perinatally, Specifically in countries where the prevalence in
the general population of chronic HBV infection is more than 8 %, the first dose of
hepatitis B vaccine should be given within 24 hours after birth to prevent perinatal
transmission.
The complete vaccine series induces protective antibody levels in more than 95%of
infants, Children and young adults .after the age of 40 years, protection following the
primary vaccination series drops below 90% by 60 years, protective antibody levels are
achieved in only 65-75% of the vaccines .the duration of protection is at least 15 years
and based on current scientific evidence lifelong. Some infants born prematurely with
low birth weight (<2000g) may not respond well to vaccination at birth. However, by
one month of chronological age all premature infants, regardless of initial birth weight
or gestational age are likely to respond adequately. In such cases the vaccine dose given
at birth should not be counted towards the primary series and 3 additional doses should
be given according to the national vaccination schedule immunosuppressive illness such
as advanced HIV infection chronic liver diease, chronic renal failure and diabetes are
associated with reduced immunogenicity of vaccine. Data on immunogenicity suggest
that in any age group, interruption of the vaccination schedule doesn’t require
restarting of the vaccine series .if the primary series is interrupted after the first dose
,the second dose should be administered as soon as possible and the second and the
third doses separated by a minimum interval of 4 weeks ,if only the third dose is
delayed, it should be administered as soon as possible .the plasma derived vaccine and

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21

recombinant vaccines show no difference in terms of reactogenicity, Efficacy or
duration of protection. Their thermo stability is also similar both should be stored at 2-
8centegreed freezing must be avoided as it dissociates antigen from the alum adjuvant.
Although both vaccines tolerate temperatures of up to 45 c for one week and of up to 37
c for one month without change in immunogenicity or reactogenicity, exposure to hot
temperature should be minimized.
All previously vaccinated should receive the vaccine hepatitis B vaccination is also
indicated for certain groups at high –risk of contracting HBV infection including
persons with high-risk sexual behavior, partners and household contacts of HbsAg
positive persons, injecting drug users, persons who frequently require blood or blood
products, recipients of solid organ transplantation, those at occupational risk of HBV
infection, including health care workers, as well as for international travelers to HBV
endemic countries .hepatitis B vaccine is contraindicated for individuals with a history
of allergic reactions to any of the vaccine’s components .neither pregnancy nor lactation
is a contraindication for use of this vaccine.
Hepatitis B immunoglobulin (HBIG):
For immediate protection, HBIG is used for those acutely exposed to HBs Ag-positive
blood, for example surgeons nurses or laboratory workers newborn infants of carrier
mothers, sexual contacts of acute hepatitis B patients, and patient who need protection
against HBV infection after liver transplantation. The HBIG should be given as soon as
possible after an accidental inoculation (ideally within 6 hours and preferably not later
than 48 hours) at the same time the victim’s blood is drawn for HBsAg testing. If the
test is negative, vaccination should be started immediately and a full course given. If the
test is positive for surface antibody, no further action is needed.
The recommended dose is 0.05 to 0.07 ml/kg of body weight. Two doses should be given
30 days apart 31, 18). HBIG provides short-term passive protection which lasts
approximately 3 months since the median incubation period is said to be lower than
100days. Two doses of HBIG given one month apart should suffice. The general use of
HBIG for long –term prophylaxis has not been recommended because of its limited
availability, its high cost and risk (although remote) of complications through repeated
use over a long period of time.
Passive-active immunization:
The simultaneous administration of HBIG and hepatitis B vaccine is more efficacious
than HBIG does not interfere with the antibody response to the hepatitis B vaccine. This
combined procedure is ideal both for prophylaxis of persons accidentally exposed to
blood known to contain hepatitis B virus, and for prevention of the carrier state in the
newborn babies of carrier mothers. HBIG (0.05-0.07ml/kg) should be given as soon as
possible and within 24 hours, if possible. Hepatitis B virus vaccine 1.0 ml (20 mcg/1.0ml)
should be given intramuscularly within 7 days of exposure and second and third doses
should be given one and six months, respectively, after the first dose.
Other measures:
All blood donors should be screened for HBV infection, and those positive for Australia
antigen should be rejected voluntary blood donation should be encouraged because
purchased blood has shown a higher risk of post-transfusion hepatitis.
Health personnel should be alerted to the importance of adequate sterilization of all
instruments and to the practice of simple hygienic measures. Carriers should be told not
to share razors or tooth brushes and use barrier methods of contraception, they should
not donate blood.
HEPATITIS C:

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Until a few years ago, the only types of viral hepatitis that could be confirmed were type
A and type B. All others were described as non-A,non B,that is neither hepatitis A nor
hepatitis B viral infection could be confirmed in blood tests of patients since the
hepatitis C virus (HCV)was identified in the year 1989, it has been shown to be the
major cause of parent rally transmitted non-A non B (PT-NANB) hepatitis.
The incidence of HCV infection worldwide is not well known, but from the review of
published prevalence studies, WHO estimates that 3 % of the world population is
chronic carriers at risk of developing liver cirrhosis and liver cancer. In many
countries, particular population sub groups such as voluntary blood donors have a very
high prevalence of HCV infection especially in the developing world. In the USA an
estimated 4 million people have contracted the disease 4 times more than HIV infection
approximately 3-4 million new acute infections and about 54000 deaths occur each year.
It has also become a leading reason for liver transplantation the annual incidence of
HCV infection in SEAR countries is largely unknown, primary because over 50% of
infections cases are asymptomatic. In adaptation many symptomatic acute HCV cases
are not laboratory –confirmed since testing of patients for HCV markers is not
commonly done. In india HCV antibodies have been found in 2 percent of voluntary
blood donors. Testing of blood samples from patients with hepatocelular carcinoma has
shown that 42%of the patients in india, 29% in Indonesia and 35 % in Myanmar had
marker of HCV infection. A high prevalence of HCV markers have also been detected
in patients with chronic liver disease. The hepatitis C virus is a single – stranded RNA
virus with properties similar to those of flavivirus. It bears no genomic resemblance to
hepatitis B or D. the virus is mainly transmitted through transfusion of contaminated
blood or blood products. Up to 50% of cases are related to intravenous drug user who
shares needles. The risk of sexual and maternal neonatal transmission is small. A low
rate of secondary transmission to household contacts has been recognized. For health
care workers it is an occupational hazard requiring adherence to universal precautions.
Traditional practices such as circumcision, tattooing and scarification with
contaminated instruments can spread HCV infection. The incubation period averages 6-
7 weeks, and clinical illness is often mild, usually asymptomatic with a high rate of
(more than 50%) chronic hepatitis, which may lead to cirrhosis of liver or liver cancer.
It may take as long as 20 year to develop into liver cancer, and is more likely to do so in
men than in women, and in alcohol consumers. Since it is not known whether all PT –
NANB hepatitis is due to HCV infection, the diagnosis of acute NANB hepatitis must
first be established in persons with signs and symptoms consistent with acute hepatitis
by ruling out acute HAV and HBV infections, only immunoassays for antibodies to part
of the non-structural region of HCV(anti-HCV) are available, as well as supplemental
recombinant immunoblot assay (RIBA) tests used to confirm anti-HCV positive results.
Patients with acute PT-NANB hepatitis who are anti. HCV negative at the onset of
illness should be tested 6 months later, and if they are anti HCV positive, the diagnosis
of acute HCV infectious as confirmed in research laboratory by use of polymerase chain
reaction to detect HCV RNA. Testing donated blood for HCV has been made
mandatory for all blood banks from july 1, 1997 major prevention problems persist in
the developing countries, many of them cannot afford the anti-HCV blood test kite,
where the use of contaminated equipment for injection and other medical and dental
procedures is widespread. Efforts are, therefore, necessary to persuade the
manufactures of tests to lower the costs for developing countries. Health education
programmes are also needed to inform the general public and health care workers,
about the risk of transmitting infection with the use of unsterile equipments.

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Surveillance on a global scale needs to be strengthened in order to improve medical
knowledge of transmission of the virus. Interferon is the only drug that has been found
effective in the treatment of HCV infection. However, treatment is very expensive –
thousands of dollars for the drug alone –and must be administered by infection several
times a week for several months. Moreover, some patients, experience serious side-
effects also, about half of the patients go into remission but 50 % relapse when the
treatment is stopped, only 25 % have long term remission. Given its cost, only a
minority of patients can afford it, or are likely to be offered it. Studies involving less
costly, orally administered drugs are continuing, but results so far have been
disappointing. For a number of technical reasons, the development of a vaccine to
prevent HCV infection is unlikely for many years.
HEPATITIS E:
The infection caused by the hepatitis E virus (HEV) which was discovered in 1980, is
essentially water- borne disease. Formerly termed enterically transmitted hepatitis non-
A, non-B (HNANB), HEV is a 29 nm to 32-nm RNA virus. Water or food supplies,
contaminated by faeces, in which the virus is excreted, have been implicated in major
outbreaks reported in all parts of the world that have a hot climate. After an incubation
period of 2-9 weeks, a self –limiting acute viral hepatitis appears, lasting for a period of
several weeks, which is followed by recovery. No case of chronic disease has been
reported by acute hepatitis E. In addition, HEV has a propensity to induce a
fulminating from of acute disease (the mortality ranges between 0.5% to 4%)
particularly in pregnant women, upto 20 % of whom may develop fulminating hepatitis
E, with mortality that reach about 80% of such cases. The importance of intrauterine
infections due to hepatitis E infection during pregnancy, responsible for abortions,
intrauterine death, and high perinatal morbidity and mortality, is currently under
investigation. The first major epidemic was reported in New Delhi in the winter of 1995
-96. After the flooding of yamuna river,30,000 cases of jaundice were described ,and
retrospectively attributed to hepatitis E .china reported 100,000 cases of jaundice
between 1986 and 1988. Since then, additional outbreaks have been reported from
Borneo, India, Indonesia, Mexico, Nepal, Pakistan etc. However, hepatitis E outbreaks
or even sporadic cases are rare in temperate climates. In central Europe and in North
America, hepatitis E has been diagnosed only in patients returning from countries with
high endemicity for viral hepatitis. But screening of blood donors in these areas has
shown a prevalence of anti-HEV antibodies upto 2.5% the findings were similar for
blood donors from south Africa (1.4%)and Thailand (2.8%) seroprevalence in blood
donor (9.5%and 24% respectively )diagnosis is made by the level of anti-HEV
antibodies in the serum. No confirmatory assay is currently available anti-HEV IgM
antibodies have been determined; however, their usefulness for the diagnosis of acute
hepatitis E infection remains to be confirmed.
Hepatitis E appears to be widespread problem in developing countries where there are
problems in providing safe drinking water and adequate sewage disposal. General
precautions against the infection are as outlined for hepatitis A for prevention, travelers
to highly endemic areas are recommended to take the usual elementary food hygiene
precautions. There is no specific treatment for hepatitis E. only supportive measures are
required. Recovery from hepatitis E is always complete. No vaccine or specific
immunoglobulin prophylaxis is available .preliminary studies in primates indicate that
protection through vaccination may be achievable in the foreseeable future.
HEPATITIS D:

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HDV is found throughout the world but with a non- uniform distribution. Its highest
prevalence has been reported in Italy, the Middle East, central Asia West Africa and
South America. HDV infects all ages. Persons who have received multiple transfusions,
intravenous drug abusers, and their close contacts are at high risk. The primry route of
transmission is believed to be similar to those of HBV, though HDV does not appear to
be sexually transmitted disease. Infection is dependent on HBV replication, as HBV
provides an HBs Ag envelop for HDV the incubation period varies from 2-12 weeks
,being shorter in HBV carriers who super infection with the agent than in susceptible
persons who are simultaneously infected with both HBV and HDV. HDV has been
transmitted perinatally, but for tunately it is not prevalent in region of the world, such
as Asia, where perinatal transmission of HBV occurs frequently. Two epidemiological
patterns of HDV infection have been identified. In Mediterranean countries, HDV
infection is endemic among persons with hepatitis B, and most infections are thought to
be transmitted by intimate contact. In non endemic areas, such as United states and
northern Europe, HDV infection is confined to persons exposed frequently to blood and
blood products,drug addicts and hemophiliacs. HDV can be prevented by vaccinating
HBV susceptible persons with hepatitis B vaccine. However, vaccination does not
protect hepatitis B carriers from super infection by HDV.
HEPATITIS G:
Hepatitis G virus HGV was discovered in 1996. The prevalence of this infection is still
not known. A few publications provide information on the association of this infection
with blood transfusion in india. The nomenclature and definition used in the disease are
shown. Table 3

Nomenclature and definitions of hepatitis viruses, antigens and antibodies
Disease Component of system Definition

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Hepatitis A HAV hepatitis A virus etiologic agent of infectious hepatitis
Is A .picornavirus, the prototype of a new genus,
Hepatovirus.
Anti-HAV Antibody to HAV .Detectable at onset of symptom
; lifetime persistence.
IgM anti-HAV IgM class antibody to HAV .indicates recent
Infection with hepatitis A: positive up to 4-6 months
After infection.
Hepatitis B HBV hepatitis B virus. Etiologic agent of serum hepatitis
A hepadnavirus.
HBsAg hepatitis B surface antigen .soluble antigen (s) of
HBV detectable in large quantity in serum ; several
Sub types identified.
HBeAg hepatitis Be antigen .soluble antigen: associated with
HBV replication ,with high titers of HBV in serum and
With infectivity of serum.
HBcAg hepatitis B core antigen .
Anti- HBs antibody to HBsAg .indicates past infection with and
Immunity to HBV ,presence of passive antibody from
HBIG, or immune response from HBV vaccine .
Anti -HBe antibody to HBeAg. Presence in serum of HBsAg
Carrie suggests lower titer of HBV .
Anti-HBc antibody to HBcAg. Indicates infection with HBV at
Some undefined time in the past.
IgM anti-HBc IgM class antibody to HBcAg. Indicates recent infection
With HBV :positive for 4-6 months after infection.
Hepatitis HCV hepatitis C virus, a common etiologic agent of post
Transfusion hepatitis . A flavivirus, genus hepacivirus.
Anti-HCV Antibody to HCV.
Hepatitis D HDV hepatitis D virus . etiologic agent of delta hepatitis :
Causes infection only in presence of HDV.
HDVAg Delta antigen ( delta –Ag ) Detectable in early acute
HDV infection.
Anti HDV Antibody to delta Ag (anti delta) indicates past or presenct
Infection with HDV.


Hepatitis E HEV hepatitis E virus. Enteric ally transmitted hepatitis virus.
Causes large epidemics in Asia and North Africa : faecal
Oral or waterborne transmission. perhaps a calicivirus
Hepatitis G HGV hepatitis G virus. A flavivirus.
Immune globulins IG immune globulin USP. Contains antibodies to HAV:
No antibodies to HBs Ag, HCV, or HIV.
HBIG hepatitis B immune globulin contains high titers of
Antibodies to HBV

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Chapter 2: Literature Review
A Knowledge, Attitude and Practice KAP Study on Hepatitis in institute of health
science Nangarhar Afghanistan
Literature Review: It is defines as “the process of reading analyzing, evaluating and
summarizing scholarly materials about a specific topic”
The results of a literature review may be complied in a report or they may serve as part
of a research article, theses or grant proposal/or protocol.
A literature review is a body of text that aim to review the critical points of current
knowledge including substantive findings as well as theoretical and methodological
contribution to a particular topic literature reviews are secondary sources and as such
do not report any new or “original experimental work”.
Most often associated with academic oriented literature, such as a thesis, a literature
review usually precedes a research protocol and result section. Its ultimate goal is to
bring the reader up to date with current literature on a topic and forms the basis for
another research that may be needed in the area.
A well-structured literature review is characterized by a logical flow of ideas; current
and relevant references with consistent, appropriate referencing style, proper use of
terminology; and an unbiased and comprehensive view of the previous research on the
topic.
Definition of the problem under study:
KAP – study on Hepatitis
KAP stands for Knowledge, Attitude and Practice.
When we think of a means or suggests the same as the semantics of its three components
i.e. K = knowledge, A = attitude and P = practice. The reason why I chose a KAP –
study on Hepatitis is manifold, firstly the issue of Hepatitis is social taboo and there is
little awareness among the general public about it and how to prevent it being
contracted. Secondly it is along with other contagious diseases a leading and emerging
problem adding to the disease burden when we speak from the perspective of
Afghanistan of the broader South Asia Region, courtesy immigration/emigration
patients and its effects on local population demographics.
What does the WHO go from here? If they do nothing and continue believing that
increased infection is not a threat, what might be the costs?
If they aggressively work to decrease the spreads of the disease what are the costs?
Should the WHO take a middle-road strategy and research their assumption before
deciding on an action plan?
Chapter 3: Methodology
Objective:
It is a descriptive KAP assessment of Hepatitis of the students of institute health science,
Nangarhar
To assess the knowledge of the students of institute health science Nangarhar on
Hepatitis.
To assess the attitude of the students of institute health science Nangarhar towards the
hepatitis.
To assess the practices regarding Hepatitis among the students of institute health
science Nangarhar.

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Hypothesis:
The students of the institute health science have sufficient awareness about Hepatitis
and it prevention.
Study Site
Nangarhar the province of Afghanistan has area square 7727 km²
The Population of Nangarhar 1.436 million.
(2013)

The Abasyn University Peshawar is the one of leading management university of KPK.
Abasyn University is offering degree programs for:
Business administration.
Management.
Information technology.
Public health.
These are all similarly tied knowledge bases that help create synergy and foster the
cross fertilization of knowledge. The current position of the Abasyn University as a
forerunner in education provision has come about as a unique case of self sustained
development. This was made possible by a dedicated staff that had the creativity to
grow beyond the narrow confines of state provided education. Most of the universities
in Pakistan have been in stasis for decades now, but the Abasyn University has been one
of the few examples of successful growth in academia, one that has become a
benchmark of quality for others.

The Abasyn University Peshawar is a one of best management university of KPK in
Business school in the region began as a bold experiment that at once reformed public
sector higher education and became a revolutionary model for the academic world. This
government body of higher education grew out of the University of Peshawar; however,
as a public sector academic institution, its uniqueness lies in its dual status as an
autonomous government body. This self-governing administrative structure facilitates a
more dynamic adaptation to the rapidly changing demands of the academic and
professional worlds. The Institute’s independent organizational structure also allows for
a larger endowment which enables students from diverse social and cultural
backgrounds to benefit from the institute’s pledge of world-class education.

Study Design
A cross-sectional descriptive quantitative research about Knowledge Attitude and
Practices (KAP) of the students of the institute health science, Nangarhar was done
through structured questionnaire.
Sample Size
The targeted population for this study was the students of institute health science
Nangarhar. Questionnaires were distributed and asked the students to fill. Questioners
were distributed to both genders male. The total intended sample size selected
subjectively was 110 from among whom 100 responded.
Sample Selection
The selection of sample was done through convenient sampling, irrespective of gender
age group and discipline of studies.
Data collection
The data was collected through structured questionnaire. The questionnaire used in the
study was closed ended and it was written in English language.

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The questionnaire had four main sections.
The first section was about the socio-demographic information e.g. age, gender, marital
status, education, etc.
The second section was regarding the Knowledge of towards HEPATITIS.
The Third section was regarding the Attitude towards Hepatitis.
The fourth section was regarding the Practice of prevention against Hepatitis.
Before the distribution of questionnaire, the respondents were well informed, about the
background and importance of the study.
Pilot study
To check the response of respondent and to mistake free questionnaire. A pilot study
was practiced on the same population of the students of institute health science.
Slight changes have made in order to make it feasible for them.
Budgets for the Study
Basically, it was the part of MMSPH 6th semester. So, this study was self budgeted.
Data analyses
Data is analyzed by using SPSS (Statistical Package for Social Sciences) and Microsoft
Excel 2007

29. 29



29

Chapter 4: Analysis
Data Analysis
Result: The Total of 100 Questionnaires was distributed among the students of institute
health science Nangarhar. Out of 100 questionnaires 100 completed questionnaires were
returned while.
The total 100 questionnaire was distributed and100 were returned, so the response rate
was 100 %

30. 30



30

: Sex
N Percentage
Female 10 10.0
Male 90 90.0
Total 100 100.0
Male and feamle students.

Figure 4: Sex





0
10
20
30
40
50
60
70
80
90
100
Candideties total
Male
Female
Total

31. 31



31



Candidates percentage
Nurse 30 30.0
Lab technetion 35 35
Dents 15 15.0
Pharmacy technetion 20 20
Total Candidates 100 100
Figure:5 0
10
20
30
40
50
60
70
80
90
100
% totalno % total
Nurse
Lab technetion
Dents
pharmacy technetion
3-D Column 5

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32

Table 6: Do you know hepatitis ?
Candidates yes no I don’t know
Lab tech 34 1 0
Nurse 29 1 0
Pharmacy tech 17 3 0
Dents 15 0 0
Total 95 5 0

Figure:6 0
10
20
30
40
50
60
70
80
90
100
yes noI don,t
know
Lab tech
Nurse
pharmacy tech
Dents
Total

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33

Table 7: Have you ever heard ,watched / read about hepatitis?
Candidates yes no I don’t know
Lab tech 32 2 1
Nurse 26 3 1
Pharmacy tech 13 7 0
Dents 14 1 0
Total 85 13 2




0
10
20
30
40
50
60
70
80
90
yes noI don,t
know
Lab tech
Nurse
pharmacy tech
Dents
Total

34. 34



34



Figure:8 Hepatitis is a big problem as media suggests?


Candidates yes no I don’t know
Lab tech 24 9 2
Nurse 16 11 3
Pharmacy tech 15 2 3
Dents 10 1 4
Total 65 23 12
0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentis
Total

35. 35



35

Figure 9 : Is there any vaccines for hepatitis?
Candidates yes no I don,t know
Lab tech 28 6 1
Nurse 20 4 6
Pharmacy tech 14 4 2
Dentist 11 0 4
Total 73 14 13



0
10
20
30
40
50
60
70
80
yesnoI don.t
know
Lab tech
Nurse
pharmacy tech
Dentist
Total

36. 36



36

Figure 10 : Can hepatitis be cured by medicine?
Candidates yes no I don’t know
Lab tech 24 3 8
Nurse 22 5 3
Pharmacy tech 13 4 3
Dentist 8 2 5
total 67 14 19




0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
total

37. 37



37

Figure 11 : that can happen to all people?
Candidates yes no I don,t know
Lab tech 21 12 2
Nurse 16 8 6
Pharmacy tech 13 4 3
Dentist 11 1 3
Total 61 25 14



0
10
20
30
40
50
60
70
yesnoI don,t
know
Lab tech
Nurse
pharmacy tech
Dentist
total

38. 38



38

Figure 12 : hepatitis educational program is necessary for students?
Candidates yes no I don’t know
Lab tech 29 4 2
Nurse 23 1 6
Pharmacy tech 13 4 3
Dentist 11 1 3
Total 76 10 14


0
10
20
30
40
50
60
70
80
yesno I don,t
know
Lab tech
Nurse
pharmacy tech
Dentist
total

39. 39



39

Figure 13 : healthy looking transmit hepatitis?
Candidates yes No I don’t know
Lab tech 24 7 4
Nurse 25 2 3
Pharmacy tech 12 3 5
Dentist 7 7 1
total 59 19 22
0
10
20
30
40
50
60
yesnoI don,t
know
Lab tech
Nurse
pharmacy tech
Dentist
total

40. 40



40

Figure 14 : hepatitis can be spread by social kissing hepatitis infected personts?
Candidates Yes No I don’t know
Lab tech 19 9 7
Nurse 11 11 7
Pharmacy tech 13 4 3
Dentist 5 8 2
total 49 32 19

0
5
10
15
20
25
30
35
40
45
50
yesnoI don,t
know
Lab tech
Nurse
pharmacy tech
Dentist
Total

41. 41



41


Figure 15 ; hepatitis can be insect or mosquito bite?
Candidates yes no I don,t know
Lab tech 10 17 8
Nurse 8 16 6
Pharmacy tech 13 4 3
Dentist 4 5 6
Total 35 42 23
0
5
10
15
20
25
30
35
yesnoI don,t
know
Lab tech
Nurse
pharmacy tech
dentist
total

42. 42



42


Figure 16: hepatitis can be spread by sexual intercourse, with hepatitis infected
personts?

Candidates Yes No I don’t know
Lab tech 23 7 5
Nurse 13 4 3
Pharmacy tech 15 2 3
Dentist 11 3 1
Total 62 16 12

0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
total

43. 43



43

Figure 17: Hepatitis infected mothers to their new borne?
Candidates Yes No I don’t know
Lab tech 24 6 5
Nurse 19 3 8
Pharmacy tech 18 1 1
Dentist 11 3 1
Total 72 13 15

yes noI don,t
know
lab tech
Nurse
pharmacy tech
dentist
total
l

44. 44



44

Figure 18: hepatitis can spread by breast feeding?
Candidates yes no I don,tknow
Lab tech 9 11 15
Nurse 22 1 7
Pharmacy tech 13 6 1
Dentist 7 3 4
Total 51 21 27


0
10
20
30
40
50
60
yesnoI don,t
know
4th
Qtr
lab tech
Nurse
pharmacy tech
Dentist
total

45. 45



45


Figure 19: Hepatitis can be spread by transfusion of blood donated by hepatitis
infected?
Candidates yes no I don,t know
Lab tech 25 5 5
Nurse 20 6 4
Pharmacy tech 16 2 2
dentist 12 1 2
total 73 14 13

0
10
20
30
40
50
60
70
80
yesnoI don,t
know
4th Qtr
lab tech
Nurse
pharmacy tech
Dentist
Total

46. 46



46

Figure 20: hepatitis can be spread by piercing of the ear –nose and other part?
Candidates yes no I don,t know
Lab tech 17 16 3
Nurse 17 4 9
Pharmacy tech 9 6 5
Dentist 12 2 1
Total 54 28 18



0
10
20
30
40
50
60
yes I
don,tknow
lab tech
Nurse
pharmacy tech
Dentist
total

47. 47



47

Figure 21: Hepatitis can be spread by sharing razors with hepatitis infected person?
Candidates yes no I don,t know
Lab tech 20 10 5
Nurse 20 5 5
Pharmacy tech 18 2 0
Dentist 10 2 3
Total 68 19 13



0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
total

48. 48



48

Figure 22: hepatitis can be spread by using same drinking glass or eating plates?
Candidates Yes No I don’t know
Lab tech 18 13 4
Nurse 21 8 1
Pharmacy tech 15 5 0
Dentist 7 5 3
total 61 31 8
0
10
20
30
40
50
60
70
80
yesnoI don,
tknow
lab tech
Nurse
pharmacy tech
Dentist
total

49. 49



49

Figure 23:hepatitis can not be spread by being faithful to infected person?
Candidates Yes No I don’t know
Lab tech 11 19 5
Nurse 8 17 5
Pharmacy tech 9 6 5
Dentist 6 7 2
total 34 49 17


0
5
10
15
20
25
30
35
40
45
50
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

50. 50



50

Figure 24: Can you be come infected by having unprotected sex with a person who is
infected with hepatitis?
Candidates yes no I don’t know
Lab tech 20 6 9
Nurse 21 6 3
Pharmacy tech 15 5 0
Dentist 5 2 3
Total 66 19 15


0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

51. 51



51

figure 25: polygamy (multi marriage) increases the risk of hepatitis infection?
Candidates yes no I don,t know
Lab tech 23 1 11
Nurse 11 8 11
Pharmacy tech 15 3 2
Dentist 7 3 6
Total 56 14 30

0
10
20
30
40
50
60
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

52. 52



52

Figure 26: Using of condom can protect from hepatitis infection ?
Candidates yes no I don’t know
Lab tech 28 5 2
Nurse 24 4 2
Pharmacy tech 16 2 2
Dentist 10 0 5
Total 78 11 11
0
10
20
30
40
50
60
70
80
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

53. 53



53

Figure 27:Do know casual Agent of hepatitis ?
Candidates yes no I don,t know
Lab tech 18 10 7
Nurse 8 13 9
Pharmacy tech 6 9 5
Dentist 7 5 3
Total 39 37 24


0
5
10
15
20
25
30
35
40
yes noI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

54. 54



54

Figure 28: would you be willing to stay with students who is hepatitis positive?
Candidates yes no I don’t know
Lab tech 15 15 5
Nurse 15 11 4
Pharmacy tech 8 8 4
Dentist 8 3 4
Total 46 37 17

0
5
10
15
20
25
30
35
40
45
50
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

55. 55



55

Figure 29: would you be willing to use the same toilet with students who is hepatitis
positive?
Candidates yes no I don,t know
Lab tech 16 15 4
Nurse 10 17 3
Pharmacy tech 6 10 4
Dentist 10 5 0
Total 42 47 11



0
5
10
15
20
25
30
35
40
45
50
yes noI don,t
know
Lab tech
Nurse
pharmacy tech
Dentist
Total

56. 56



56

Figure 30: would you be willing to eat food at a company prepared by worker who is
hepatitis positive?
Candidates yes no I don,t know
Lab tech 16 17 2
Nurse 6 19 5
Pharmacy tech 9 9 2
Dentist 7 7 0
Total 38 52 9


0
10
20
30
40
50
60
yes noI don,t
know
lab tech
Nurse
pharmcy tech
Dentist
Total

57. 57



57

Figure 31: would you be willing to swim in a pool with hepatitis positive person?
Candidates yes no I don’t know
Lab tech 11 22 2
Nurse 8 20 2
Pharmacy tech 8 12 0
Dentist 7 6 2
Total 34 60 6



0
10
20
30
40
50
60
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
total

58. 58



58

Figure 32: would you be willing to share a room with same one living hepatitis positive?
Candidates yes no I don’t know
Lab tech 15 15 5
Nurse 13 14 3
Pharmacy tech 10 6 4
Dentist 7 6 2
Total 45 41 14
0
5
10
15
20
25
30
35
40
45
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

59. 59



59

Figure 33: would you be willing to receive medical treatment from a health care worker
who is hepatitis positive ?
Candidates yes no I don’t know
Lab tech 16 16 3
Nurse 11 12 7
Pharmacy tech 9 7 4
Dentist 7 7 1
Total 43 42 15


0
5
10
15
20
25
30
35
40
45
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

60. 60



60

Figure 34: would you be willing to utilize the services of a barber ,or a hair dresser who
is hepatitis positive ?
Candidates yes no I don’t know
Lab tech 10 20 5
Nurse 7 22 1
Pharmacy tech 5 13 2
Dentist 6 8 1
Total 28 63 9


0
10
20
30
40
50
60
70
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

61. 61



61

Figure 35: Do you agree with volunteer testing ?
Candidates yes no I don’t know
Lab tech 25 5 5
Nurse 22 6 2
Pharmacy tech 13 3 4
Dentist 13 1 1
Total 73 15 12

0
10
20
30
40
50
60
70
80
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

62. 62



62

Figure 36: Do you agree with screening before marriage ?
Candidates yes no I don’t know
Lab tech 29 2 4
Nurse 21 7 2
Pharmacy tech 15 3 2
Dentist 12 1 2
Total 77 13 10


0
10
20
30
40
50
60
70
80
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

63. 63



63

Figure 37: Do you agree with isolation of people living with hepatitis positive?
Candidates yes no I don’t know
Lab tech 19 8 8
Nurse 18 10 2
Pharmacy tech 9 5 6
Dentist 11 2 2
Total 57 25 18



0
10
20
30
40
50
60
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

64. 64



64

Figure 38: All students should be hepatitis tested ?
Candidates yes no I don’t know
Lab tech 24 6 5
Nurse 23 5 2
Pharmacy tech 14 5 1
Dentist 11 4 0
Total 72 20 8

0
10
20
30
40
50
60
70
80
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

65. 65



65

Figure 39:Do you agree hepatitis positive patients care?
Candidates yes no I don’t know
Lab tech 24 10 1
Nurse 22 8 0
Pharmacy tech 16 2 2
Dentist 10 4 1
Total 72 24 4
0
10
20
30
40
50
60
70
80
yesnoI don,t
know
lab tech
Nurse
pharmacy tech
Dentist
Total

66. 66



66

Chapter: 5 Discussions
The purpose of this descriptive study was to assess the knowledge, attitude and the practices
of the students of initiate of health science about hepatitis.
The study is divided into three major portions, in the first part is the knowledge of the
students were tested about hepatitis. To achieve the goal a structured questionnaire was
distributed among the students and all the questions were closed ended.

67. 67



67

Chapter: 6 Conclusions
The conclusions that can be drawn from the study are that the knowledge, attitude and
practices of the students of Institute of health Sciences, regarding hepatitis is satisfactory but
it needs to be further improved.
Recommendation:
Health education and promotion regarding hepatitis is of paramount importance. Mass
media can be effectively used regarding knowledge, attitude and practice about
hepatitis.
References:
Appendix One: Questionnaire
Questionnaire
For Knowledge, Attitude and Practice about Hepatitis
Questionnaire: S. No 100 Date……/March/2017.
S. No Questions
0. Yes

1. No

2. Don’t k
now

1 Do you know hepatitis?
2 Have you ever heard ,watched ,read about hepatitis?
3 hepatitis is a big problem as media suggests?
4 Is there any vaccines for hepatitis?
5 Can hepatitis be cured by medicines?
6 That can happen to all people?
7 hepatitis educational program is necessary for Students?
8 Healthy looking transmit hepatitis?
9 Hepatitis can be spread by social kissing hepatitis
infected person?

10 Hepatitis can be insect or mosquito bite?

11 Hepatitis can be spread by sexual intercourse, with
hepatitis infected person?

12 Hepatitis infected mothers to their new borne?

13 Hepatitis can be spread by breast feeding?
14 Hepatitis can be spread by transfusion of blood donated
by hepatitis infected?

15 Hepatitis can be spread by piercing of the ear –nose and
other part?

16 Hepatitis can be spread by sharing razors with hepatitis
infected person?

17 Hepatitis can be spread by using the same drinking glass
or eating plates?

18 Hepatitis can’t be spread by being faithful to person?
19 Can you become infected by having unprotected sex with
a person who is infected with hepatitis?

20 Polygamy(multi marriage) increases the risk of hepatitis
infected?

68. 68



68

21 Using of condom can protect from hepatitis infectious?

22 Do know casual Agent of hepatitis?
23 Would you be willing to stay with Students who is hepatitis-
positive?

24 Would you be willing to use the same toilet with Students,
who is hepatitis-positive?

25 Would you be willing to eat food at a company canteen
prepared by a co-worker who is hepatitis-positive?

26 Would you be willing to swim in a pool with hepatitis
infected person?

27 Would you be willing to share a room with someone living
with hepatitis?

28 Would you be willing to receive medical treatment from a
health-care worker who is hepatitis-positive?

29 Would you be willing to utilize the services of a barber or a
hairdresser who is hepatitis-positive?

30 Do you agree with volunteer testing?
31 Do you agree with screening before marriage?
32 Do you agree with isolation of people living with hepatitis
patient?

33 All students should be hepatitis tested?
34 Do you agree hepatitis positive patients care?