Knowledge about Hepatitis B Virus and Relevant Safety Precautions among Dental Students in Kurdistan Region, Iraq

Background Hepatitis B virus (HBV) is still a major health problem worldwide, placing healthcare workers, medical and dental students, and professionals at higher occupational risk. The present study aimed to evaluate the level of knowledge about this virus and relevant safety precautions among dental students in the Kurdistan region of Iraq. Materials and methods. This cross-sectional study was conducted among the third, fourth, and fifth stage dental students of Hawler Medical, Sulaimani, and Duhok universities. Data on the students' demographic characteristics and their knowledge about HBV (16 close-ended questions) and safety precaution measures (10 close-ended questions) were collected by means of a questionnaire. Analysis of variance was used to compare the mean of knowledge and safety precaution scores. Results In total, 372 students (mean age 21.77 ± 1.31 years) completed the questionnaires. The mean scores for knowledge and safety precautions were 13.17 ± 2.09 and 8.05 ± 1.61, respectively. Respondents from Hawler Medical University showed statistically significantly higher knowledge levels than their counterparts in Sulaimani and Duhok universities (p = 0.012). Conclusions The majority of surveyed dental students are aware of HBV, its mode of transmission, infection, complications, vaccination, and safety precautions required to prevent the spreading of the virus. While the levels of knowledge about HBV and safety precautions among the dental students in the Kurdistan region of Iraq were generally acceptable, differences in knowledge level were identified between the universities, and these may be related to their educational and training programs.


Introduction
Hepatitis B virus (HBV) is classified as a DNA virus within the virus family Hepadnaviridae. Humans are regarded as the only known natural host. It circulates in the blood in concentrations as high as 108 virions per mm [1]. The virus has partially double-stranded DNA and a core antigen surrounded by a shell containing hepatitis B surface antigen which is considered the main diagnostic antigen for infection [2].
Replication of HBV happens only in the hepatic tissue. During high viral replication activity, the blood of an infected person may contain 106-1010 international units per mm, and, consequently, mucosal or parenteral contact with even a small amount of blood or body fluid may cause infection in susceptible people [3]. Annually, there are more than 50 million cases of acute HBV infections [4], with 5-10% of adults and up to 90% of infants suffering chronic infection [5]. Hepatitis B virus is considered to be the tenth leading cause of death throughout the world, and 500,000 to 1.2 million deaths per year are due to chronic hepatitis, cirrhosis, or hepatocellular carcinoma [4]. Iraq, meanwhile, is regarded to be of moderate endemicity for HBV infection, with a rate of 3% [6].
Transmission of infection in the dental practice might happen via infected needle prick, direct blood contact, saliva, and indirect contact with contaminated operative instruments or environmental surfaces [7], which can be prevented through the standard precautions adopted by the United States Centers for Disease Control and Prevention in 1996 [8]. These preventive measures must be followed by the dentist and dental team to overcome the risk of crossinfection. Moreover, the wearing of gloves by dentists and dental assistants has been recommended as a paramount component of cross-infection control [9].
Today, with the emergence and spread of the COVID-19, 6,454,184 of the world population were killed by the disease [10]. A dentist can play a crucial part in the prevention of hepatitis as well as COVID-19 infections by taking into account that each and every patient may be a potential carrier of hepatitis and COVID-19. Proper infection control measures, sterilization, and prophylactic vaccination protocols must be followed in order to minimize the risk of HBV infection, on the one hand [11], while ensuring dental care providers having a high level of knowledge is very important for their adoption of appropriate attitudes and practices regarding patients with HBV, on the other hand [12].
Accordingly, the dental staff's and dental students' knowledge and attitude are the cornerstones in the prevention of HBV infection. They are involved at the first stage of the dental health delivery system, and their coming into contact with infected patients and contaminated instruments might increase the risk of HBV and COVID-19 transmission, particularly if safety precautions are not followed correctly. As there is a lack of data on the awareness and practice among dental students in the Kurdistan region of Iraq, the purpose of the current study was to evaluate the knowledge and practice behavior of dental students, with a special focus on infection control and safety precautions that ultimately minimize transmission of this communicable disease, as well as to compare the knowledge and safety precautions regarding HBV infection among different dental colleges in the Kurdistan region of Iraq.

Materials and Methods
This cross-sectional study was conducted among the third, fourth, and fifth stage dental students of Hawler Medical, Sulaimani, and Duhok universities in the Iraqi Kurdistan region. The total numbers of dental students at these three universities were as follows: Hawler Medical University: 193 students (90 males, 103 females); Sulaimani University: 174 students (83 males, 91 females); and Duhok University: 91 students (46 males, 45 females).
Ethical approval was obtained from the Ethical Committee/College of Dentistry/University of Sulaimani. Students were informed about the study and assured of their anonymity. The close-ended self-administered validated questionnaire was prepared in English and consisted of three parts: (1) Part one related to sociodemographic characteristics of the study participants including gender, age, university, and stage (2) Part two consisted of 16 questions to determine the level of knowledge among dental students regarding HBV, its transmission, and prevention. The knowledge score for each individual was calculated by assigning a score of "1" for each "Yes" response to items (1,2,4,5,6,7,10,12,14,16) and a score of "1" for each (No) response to items (3,8,9,11,13,15). The safety precautions score for each individual was calculated by assigning a score of "1" for each "Yes" response to items (2,4,5,6,7,9,10) and a score of "1" again for each "No" response to items (1,3,8).

Statistical Analysis.
Descriptive statistics were used to measure the mean and standard deviation (SD), and a chisquare test was conducted to compare categorical variables. Analysis of variance (ANOVA) was used to compare the mean of knowledge and safety precaution scores across Sulaimani, Hawler Medical, and Duhok universities. A p value of ≤0.05 was considered significant for statistical

Results
Out  Table 2.

Safety Precautions regarding Hepatitis B Virus.
Overall, the respondents had excellent knowledge of safety precautions including washing hands prior to and after treatment procedure, after exposure to a patient's body fluid, and wearing protective face masks. A significant difference was noted among dental students of Sulaimani, Hawler Medical, and Duhok universities in relation to checking the patient's blood tests for contagious diseases before dental procedures (p = 0:018). Furthermore, 81.6% of Sulaimani respondents, followed by 78.5% of Duhok and 65.1% of Hawler Medical respondents, confirmed that they checked the indicator showing whether or not instruments have been sterilized, with statistically significant differences (p = 0004). Among the respondents as a whole, wearing gloves, washing hands, using protective gowns, and protective masks as safety precautions were reported by 90.1%, 93.5%, 82.8%, and 96.0%, respectively. In addition, 71.2% said that they wore goggles and 70.4% reported bending needles after injections and discarding them in a medical waste container (Table 3).

Comparison of Respondents' Mean Knowledge and Safety
Precautions Scores. The mean knowledge and safety precautions scores of the respondent dental students in Sulaimani, Hawler Medical, and Duhok universities were compared by means of the ANOVA test (Table 4). The mean knowledge score for the total study sample was 13.1 out of 16. Hawler Medical recorded a statistically significantly higher mean knowledge score than Sulaimani and Duhok Universities (p = 0:012). The mean score on safety precautions for the total sample was 8.0 out of 10. Duhok achieved a higher mean safety precautions score than Sulaimani and Hawler Medical universities, but the difference was not statistically significant (p = 0:222), as shown in Table 4.

Discussion
It is crucial for dental students to have sound knowledge about the hepatitis B Virus infection since the high occupational risk of this infection among medical and dental workers is well known, especially during the professional training period. Nowadays, following the emergence of COVID-19, dental students have encountered changes in the teaching format. Several containment measures have been applied to stop the pandemic contagion of the virus, including isolation, contact tracing and quarantine, physical distancing, hygiene measures, and lockdown [11,13,14]. This risk provides one of the major reasons for delivering knowledge about preventive measures and universal precautions. The mean knowledge score of the dental student respondents in the Kurdistan region (regarding Hepatitis B Virus, its transmission, and prevention) was 13.1, while the corresponding score for safety precautions was 8.0, which implies sound knowledge and positive behavior toward this infection and implementation of universal precautions.
The current research found that Hawler Medical recorded a higher mean knowledge score than Sulaimani and Duhok universities, a potential reason being that Hawler Medical University had the highest number of respondents. A similar study, conducted at Sultan Qaboos University in Sultanate of Oman, reported that the majority of the respondent students (75%) were aware that HBV is a common cause of hepatitis and 50.7% of them thought that HBV infection is preventable. Approximately 70% of them believed that screening blood for HBV renders blood safe for transfusion [15]. This result is in agreement with the present study.
In another previous study, conducted by Othman et al. in 2013 on dental students at Hawler Medical University to determine the students' level of knowledge about HBV, a high percentage of respondents (41%) showed poor knowledge about HBV and method of transmission. In contrast, the current study revealed that Hawler Medical University respondents recorded a higher mean knowledge score than those from Sulaimani and Duhok universities. This result indicates that since the previous study was conducted, students' knowledge levels and awareness regarding contagious and blood-borne diseases have improved at Hawler Medical University. Students have apparently become more acquainted with HBV, its methods of transmission, and the preventive measures required to stay safe from infection with HBV and other contagious diseases. Another explanation for the higher level of knowledge among Hawler Medical University respondents in the current study is that the sample size was larger than in the previous study. The small sample size and the fact that the respondents were drawn only from Hawler city may have made it difficult to detect factors with a statistically significant association with students' knowledge levels [16].
Several recent studies also recorded unsatisfactory findings related to dental students' knowledge, attitudes, and behavior regarding HVB, and all these studies suggested the necessity of conducting mandatory continuous health education courses among healthcare providers, including dental students, and involving social media, to spread the key messages regarding transmission and prevention of HBV alongside conventional educational courses for healthcare providers [17][18][19]. For example, A study by Eisa et al. [20], conducted among first-year medical sciences students in Jazan University, Saudi Arabia, reported only moderate (57.1%) mean knowledge of the mode of transmission among the respondents. The reported mean percentage of positive beliefs and attitudes of 40.4% reflects a poor attitude regarding HBV [20]. As the study was conducted on firstyear students, a low level of knowledge among those students was to be expected. The study outcome reinforces calls for the provision of intensive courses about the transmission of infectious and blood-borne diseases among medical staff and as part of rigorous educational and training programs on infection control measures for students prior to graduation [21]. However, other studies have reported adequate knowledge among dental students, with proper implementation of standard infection control measures in dental practice, suggesting that a higher knowledge level among dental students plays a major role in establishing the right attitudes and practices [12,22]. The above-discussed results reveal differences among dental students regarding their knowledge, attitude, and awareness about the hazard of HBV and risk of transmission and spread among the community. This is linked to variation in the level of education and standards of teaching in these universities, with the majority of data obtained from developing countries and those showing good responses indicating a higher level of education at their universities.
Although the large sample size is considered a point of strength of the current study, the study had some limitations. First, the close-ended type of questioning could not reveal exact details of the respondents' knowledge and practice. Furthermore, the current study was conducted among dental students alone without including other dental care providers such as dental assistants and other teaching staff that play a major role in the effective implementation of infection control methods.
HBV is a worldwide healthcare problem, with oral healthcare providers at especially high risk of infection. HBV is a blood-borne virus that can be transmitted in dental practice by contaminated instruments and via percutaneous and mucocutaneous exposure to saliva and blood of infected patients. Healthcare workers in general and oral healthcare providers, in particular, are continuously exposed to infected fluids from the oral cavity and are at a high risk of contracting and transmitting this virus. Since all other oral healthcare providers, such as hygienists and dental assistants and other teaching staff, as well as dental students, are involved in controlling infection of HBV, it is suggested that all oral care providers in dentistry colleges need to participate, along with dental students and teaching staff, in a wider study to provide further details about their role in the transmission and/or prevention of HBV in Kurdistan region.
Results of the current study showed a need to further improve knowledge and practice of protection among dental students and to raise levels of awareness regarding the transmission of HBV among the students and patients during their daily practice of dentistry tasks, in addition, to conduct mandatory vaccination programs for the students and other staff in contact with the patients. Furthermore, there needs to be greater emphasis on certain areas of transmission of HBV and safety precautions such as checking patients' blood test results before dental procedures.
Recently with the emergence of COVID-19 pandemic worldwide, dentistry is considered a transmission source of HBV, HIV, and COVID-19. Despite the acceptable level knowledge of protection, transmission, and spread of infectious diseases, increasing knowledge and raising students' perception are required particularly in dental schools by 6 Journal of Environmental and Public Health the authorized university staff by adding further preventive modules to the preclinical learning courses. Furthermore, the dentists' attitudes and practices toward using personal protection equipment have changes dramatically in recent years due to the COVID-19 pandemic. In Iraq, a study indicated that the dentists had satisfactory levels of practices and positive attitudes toward using personal protection equipment [23]. Thus, the changes in attitude and practice toward HBV infection need further investigation. It is important to acknowledge that some differences were identified between Hawler Medical, Sulaimani, and Duhok universities which may be related to their educational and training programs. The students' knowledge can be further enhanced by adopting continuous dental education programs, seminars, and workshops about hepatitis B infection at the institutional level as "awareness is empowering." It is suggested that a separate study should be conducted on the curricula and vaccination policies of the medical/dental colleges, and finally, a program of complete vaccination and health education is recommended for all first-year students in all allied health colleges in our region.

Conclusions
The present study concluded that the majority of the respondents are aware of HBV, its mode of transmission, infection, complications, vaccination, and safety precaution measures to prevent the spreading of the HBV. Moreover, these dental students feel that it is very important that dentists, dental auxiliaries, students, and patients are immunized against HBV. Despite the level of knowledge of HBV and use of safety precautions among the dental students in the Kurdistan region of Iraq being generally acceptable, some differences were identified between the three universities, Hawler Medical, Sulaimani, and Duhok, which may be related to variations in their educational and training programs.

Data Availability
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.