Hepatitis C: Knowledge, Attitudes and
Orthopedic trainee surgeons in Pakistan
A.R. Khan, MD;
A.A. Haleem, MBBS;
F.N. Khan, MD;
A. Gul, MD;
A.R. Sarwari, MD
Hepatitis C virus (Hepatitis C Virus), the major
causative agent of non-A and non-B hepatitis, poses a serious worldwide
health problem. An estimated 100 million individuals worldwide are
chronically infected with Hepatitis C Virus. High prevalence rates have been found in
Southeast Asian countries, such as Thailand, Malaysia and India.1-3
Hepatitis C is the most common chronic blood-borne infection in the U.S.4
In Pakistan, the seroprevalence of Hepatitis C Virus is 6.7% in women and 1.3% in
children.5 Hepatitis C accounts for approximately 20% of
cases of acute hepatitis, 70% of chronic hepatitis and 30% of end-stage
liver disease in the U.S.6
The hepatitis C virus is a
single-stranded RNA virus of the Flaviviridae family. Individual
isolates consist of a closely related yet heterogeneous population of
viral genomes (quasispecies). Probably as a consequence of this genetic
diversity, Hepatitis C Virus has the ability to escape the host’s immune surveillance,
leading to a high rate of chronic infection. The extensive genetic
heterogeneity of Hepatitis C Virus has important diagnostic and clinical implications,
perhaps explaining the variation in clinical course, difficulties in
vaccine development, and lack of response to therapy.7
Hepatitis C Virus is generally transmitted by the
parenteral route. It is also transmitted by needle-stick injuries,
sexual contact, and vertically from mother to fetus.8
Hepatitis C exposure and antibody positivity rates among injection drug
users have been reported to be higher than 50% compared to 10% in the
same general population.9-12 Other known risk factors include
ear piercing, acupuncture, tattoos, and cultural procedures involving
blood contact.13-15 The use of inadequately sterilized
undisposable medical materials, e.g., needles and scalpels, has also
been shown to transmit Hepatitis C Virus.16
There is some evidence of
occupational and nosocomial transmission of Hepatitis C Virus infection. Inadvertent
needle-stick injuries and lack of application of universal precautions
may be contributing factors.15 About 80% of Hepatitis C Virus-positive
surgical operation room personnel in a hospital in Pakistan had more
than four needle-stick injuries per year in five
From the Departments of Medicine and
Orthopedic Surgery, The Aga Khan University Hospital, Karachi, Pakistan.
Address reprint requests and
correspondence to Dr. Sarwari: Department of Medicine, The Aga Khan
University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800,
Accepted for publication 20 October
2000. Received 23 November 1999.
years.17 In one Pakistani
community, Hepatitis C Virus seroprevalence was 6.5%, and individuals who received
more therapeutic injections were found to be at a higher risk of
Data on the natural history of Hepatitis C Virus is
limited because the onset of infection is often unrecognized, and the
early course of disease is indolent and protracted in most individuals.19
Approximately 60%-70% of Hepatitis C Virus patients have no discernable symptoms,
20%-30% may have jaundice, and 10%-20% may have nonspecific symptoms
(e.g., anorexia, malaise, or abdominal pain). About 75%-85% go on to
develop chronic hepatitis.4 Research indicates that 10%-20%
of chronically infected individuals are likely to develop cirrhosis over
a period of 20-30 years, while 1%-5% may go on to develop hepatocellular
carcinoma. Reports from Pakistan show that 22%-33% of biopsy-proven
cases of hepatocellular carcinoma had Hepatitis C Virus infection.20,21
The volume of epidemiological data
concerning hepatitis C is small compared with that concerning other
infectious diseases such as AIDS and hepatitis B. The few knowledge,
attitude and practice (KAP) studies concerning AIDS and hepatitis B have
concluded that KAP concerning these diseases are severely deficient
among health care professionals. Awareness is particularly crucial in
the case of hepatitis C as: 1) there is no vaccine currently available
(unlike hepatitis B);22 and 2) infected persons serve as a
source of transmission to others and are at a risk for chronic liver
disease during the first two or three decades.4
Since surgical specialty residents
have regular contact with Hepatitis C Virus patients, they should be aware of the
dangers of the condition and the necessary precautions that need to be
taken. Our study targeted this group of health care personnel, as their
knowledge, attitudes and practices are crucial in the management of Hepatitis C Virus.
Subjects and Methods
Orthopedic trainee surgeons from
three provinces and seven cities in Pakistan were surveyed. These
residents are normally directly exposed to blood products and to
incidents like needle pricks during the procedures they participate in.
Our aim was to determine the knowledge, attitude and practices of these
Data collection was carried out using
a self-administered, close-ended structured questionnaire. The
questionnaire was distributed to orthopedic surgery residents at the
Annual Orthopedic Review Course in 1998 at the Aga Khan University
Hospital, Karachi. Only participants who were part of an orthopedic
residency program at the time were chosen. Respondents were given a
10-minute briefing on the aims of the study. One researcher was present
during the survey administration to answer queries raised by
respondents. The administration of the questionnaire lasted around half
All 43 residents except one were
male. Their ages ranged from 26 to 43 years, with a median of 32.5
years. The year of graduation was between 1980 and 1997, with a median
year of 1990. The average number of years spent in the orthopedic
surgery program was four years.
Level of Hepatitis C knowledge
Only 16% of the surgical residents
knew that there was a vaccine for hepatitis A. Though 84% knew that
there was no vaccine for hepatitis C, the majority (56%) were unaware
that Hepatitis C Virus was a sexually transmitted disease and 82% did not know about
the possibility of it being transmitted perinatally. Of all the
subjects, 93% knew that Hepatitis C Virus could be transmitted through blood
transfusion and 88% knew about its transmission through a needle-stick
injury. As well, 65% did not know that Hepatitis C Virus is initially asymptomatic.
Knowledge about the complications of Hepatitis C Virus was adequate. Most of the
residents were unaware of the physical properties of the virus, i.e.,
what destroys it, thus they incorrectly estimated the seroconversion
rates with exposure to patients. This finding correlates with another
study.23 Overall, there were significant gaps in the
knowledge of the hepatitis C virus transmission.
Practices regarding Hepatitis C
Seventy-four percent of subjects had
been vaccinated for HBV. This is an encouraging finding and was found to
be better than the vaccination prevalence of 59% in a western study.23
When handling a known case of Hepatitis C Virus, 87% of subjects used an extra pair of
gloves, while only 50% took extra care with needles. This particular
finding is consistent with their poor knowledge of the higher risk of
infectivity of Hepatitis C Virus with needle pricks. Most subjects used two pairs of
gloves except for minor surgeries. The median number of surgeries
participated in was 12 in the previous month, 150 in the previous year
and 300 in the previous three years. The median number of needle pricks
was one in the previous month, three in the previous year and five in
the previous three years. Only 16% of subjects knew the serostatus of
the patients they were pricked from, and only a similar number checked
their own serology after a needle-prick injury. The gravity of the
situation is amplified by the fact that only 28% of the residents knew
their own serostatus for Hepatitis C Virus compared to 60% for HBV. Another
significant finding was that 60% of the trainee surgeons were in habit
of handling needles with their bare hands.
With regards to attitudes towards Hepatitis C Virus,
42% of the respondents said they would tell their patients about their
own Hepatitis C Virus seropositivity and 64% of residents did not believe in
interferon therapy. Of all the respondents, 40% were in a habit of
reading medical literature at least once a week.
The emergence of Hepatitis C Virus as an important
blood-borne pathogen compels us to focus our attention on protecting
health care workers from illness, disability or death.24 For
surgeons, the prevalence of infection with Hepatitis C Virus increases with increasing
age.25,26 Awareness of the dangers of this infectious disease
should be instilled at an early stage of a surgeon’s training.
According to Johanet et al., out of
3554 operative procedures (visceral, orthopedic and vascular), 4% of
procedures were associated with percutaneous exposure of blood, and
surgeons were involved in 51% of cases of percutaneous exposure.27
Hepatitis C Virus and HBV are more important than HIV as a cause of morbidity and
death of surgeons.28 The policy of standard precautions is
not observed in all hospital operation theaters. The need to implement
standard precautions is reinforced by the fact that despite the
knowledge of how to handle hepatitis C patients, 49% of the respondents
in one study could not avoid handling of blood. Similarly, handling
needles with bare hands shows a need for physician education in standard
precautions against blood-borne diseases.
The fact that only 16% of the
subjects were in the habit of checking their own serology after a
needle-prick injury shows a lack of screening of both patient and
victim, which should be a part of a hospital-wide protocol to be
followed after occupational exposure to blood and body fluids. The
recommended protocol to be implemented is to get baseline testing for
anti-Hepatitis C Virus for the source. For the person exposed to an Hepatitis C Virus-positive
source, recommendations include baseline testing for anti-Hepatitis C Virus and ALT
activity, with follow-up tests for both at four to six months.
Confirmation by supplemental anti-Hepatitis C Virus testing of all positive enzyme
immunoassay results should be done.4
In the light of the above results,
changing the attitude of health care workers towards Hepatitis C Virus becomes
increasingly important. We suggest that all new surgical residents who
are at risk of exposure to blood should be given a pre-test, a lecture,
a demonstration of standard precautions and infection control
procedures, followed by a post-test. This approach has proven to be
effective and is recommended.29 McCarthy et al. have
emphasized that orthopedic trauma surgeons need to improve their
compliance with infection control recommendations.30 Further
efforts by the individuals and their institutions are warranted.
The risk of nosocomial transmission
of HIV, HBV and other blood-borne pathogens can be minimized if
health-care workers adopt the following general guidelines:4,31
- Take care to
prevent injuries when using needles, scalpels, and other sharp
instruments or devices, when handling sharp instruments after
procedures, when cleaning used instruments, and when disposing of used
- Do not recap
used needles by hand; do not remove used needles from disposable
syringes by hand, and do not bend, break, or otherwise manipulate used
needles by hand. Place used disposable syringes and needles, scalpel
blades, and other sharp items in puncture-resistant containers for
- Use protective
barriers to prevent exposure to blood, body fluids containing visible
blood and other fluids to which universal precautions apply. The type
of protective barrier(s) should be appropriate for the procedure being
performed and the type of exposure anticipated.
- Immediately and
thoroughly wash hands and other skin surfaces that are contaminated
with blood, body fluids containing visible blood, or other body fluids
to which universal precautions apply.
- Use gloves for
performing all phlebotomy procedures.
- Suwanagool S,
Tieangrim S, Ratasanuwan W, et al. Seroprevalence of anti-Hepatitis C Virus-infected
persons and general population. J Med Assoc Thailand 1995;76:611-7.
- Irshad M,
Archarya SK, Joshi YK. Prevalence of hepatitis C virus antibodies in
the general population and in selected groups of patients in Delhi.
Indian J Med Res 1995;102:162-4.
- Duraisamy G,
Zuridah H, Ariffin MY. Prevalence of hepatitis C virus antibodies in
blood donors in Malaysia. Med J Malaysia 1993:48:313-6.
- Morbidity and
Mortality Weekly Report. Recommendations for prevention and control of
hepatitis C virus (Hepatitis C Virus) and infection and Hepatitis C Virus-related chronic disease.
MMWR 1998;47:No. RR-19.
- Parker SP, Khan
HI, Cubitt WD. Detection of antibodies to hepatitis C in dried blood
spot samples from mothers and their offspring in Lahore, Pakistan. J
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- Alter MJ, Mast
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Institutes of Health Consensus Development Conference Panel Statement.
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- Alter MJ, Hadler
SC, Judson FN, Mares A, Alexander J, Hu PY, et al. Risk factors for
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infection. JAMA 1990;264:2231-5.
- Fingerhood MI,
Jasinski DR, Sullivans JT. Prevalence of hepatitis C in a chemically
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- Mayyaon S,
Shuofman EN, Engelhard D, Shouval D. Exposure to hepatitis B and C and
HTLV-1 and HTLV-2 among Israeli drug abusers in Jerusalem. Addiction
- Van Ameijiden EJ,
van den Hock JA, Mientjes GH, Cantino RA. A longitudinal study on the
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among drug users in Amsterdam. Eur J Epidemiol 1993;9:255-62.
- Woodfield DG,
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- Kiyosawa K,
Tanaka E, Sodeyama T, et al. Transmission of hepatitis C in an
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- Mele A, Corona
R, Tosti ME, et al. Beauty treatments and risk of parenterally
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C, Van Raden M, Gibble J, Melpolder J, Shakil AO, Viladomiu L, et al.
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to have hepatitis c infection. N Engl J Med 1996;334:1691-6.
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Am J Gastroenterol 1995;9:794-9.
- Mujeeb SA,
Khatri Y, Khanani R. Frequency of parenteral exposure and
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- Luby SP,
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Beeching NJ, Tariq WU, Hart CA, Ahmad N, et al. The occurrence of
hepatitis B and C viruses in Pakistani patients with chronic liver
disease and hepatocellular carcinoma. Epidemiol Infect
- Abdul-Majeed S,
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surface antigen and Hepatitis C Virus antibodies in hepatocellular carcinoma cases
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