KNOWLEDGE ATTITUDE AND PRACTICE OF POST EXPOSURE PROPHYLAXIS BY STUDENTS AND CLINICAL STAFF AT DENTAL SCHOOL

. --. KNOWLEDGE ATTITUDE AND PRACTICE OF POST EXPOSURE PROPHYLAXIS BY STUDENTS AND CLINICAL STAFF AT DENTAL SCHOOL INVESTIGATOR SAHIL lviukesh POPAT V28/10523/06 BDS III STUDENT SCHOOL OF DENTAL SCIENCES UNIVERSITY OF NAIROBI EXTERNAL SUPERVISOR DR GATHECE BDS (UON) MPH (UON) CHAIRPERSON DEPARTMENT OF PERIODONTOLOGYIPREVENTIVE AND COMMUNITY UNIVERSITY OF NAIROBI A community dentistry project proposal submitted in fulfillment of the degree of bachelor of dental surgery at the university of Nairobi 2009 Duration of the study: June - October 2009 Cost of study: KSHS 7620 Source of funds: self, I

"~--"". "!.-" io" AUGUST2009 The chairman, KNH/UON Ethics, Research and Standards Committee, Kenyatta National Hospital. Through, \~lo \ ~\ DATE. External Supervisor Dr. GATHECE SIGNATURE ~~~... DATE L.1~l..tJ?S. Dear Sir/Madam, RE: COMMUNITY DENTISTRY PROJECT BY BOS LEVEL THREE. REG.NO V28!10523!2006 As part of the BDSdegree, the 80S students attending the University of Nairobi are required to carry out research to compile a project report. The proposal and the project account for 30% of the total marks in community and preventive dentistry subject. The research project is then examined at the departmental student is allowed to proceed with the collection of data. level by the assigned supervisor before the This is a request to your office to grant permission for the collection of data and for your assistance. Yours faithfully, SAHILPOPAT

TABLE OF CONTENTS TITLE TABLE OF CONfENTS LIST OF ABBREVIATIONS ABSTRACT INlRODUCTION LITERATURE REVIEW STATEMENT OF RESEARCH PROBLEM, OBJECTIVES METHODOLOGY STUDY AREA STUDY POPULATION VARIABLES DEPENDENT VARIABLES INDEPENDENT VARIABLES SAMPLING SAMPLING UNIT SAMPLING METHOD DATA COLLECTION TOOLS INCLUSION AND EXCLUSION CRITERIA ETHICAL CONSIDERATIONS MINIMIZATION OF ERRORS AND BIAS EXPECTED BENEFITS PROPOSED BUDGET REFERENCES APPENDIX 1 QUESTIONNAIRE APPENDIX 2 CONSENT FORM JUSTIFICATION PAGE 11l IV I 2 5 AND 6 8 o 8 8 8 8 9 9 9 10 10 10 11 11 12 13 14 14 16 16 III

Abbreviations ARVs HCW HIV KNH PEP ILO IOU NGO NRTI NI t.'f"""i"'t"' rsrv II PEP PI SOP STI UNHCR Human Rights VCT WHO Antiretroviral (medicines) Health-care worker Human immunodeficiency virus Kenyatta National Hospital Post exposure prophylaxis for HIV International Labour Organization Injection drug use(r) Non governmental organization Nucleoside reverse transcriptase inhibitor Non-nucleoside reverse transcriptase inhibitor Post-exposure prophylaxis Protease inhibitor Standard operating procedure Sexually transmitted infection Office of the United Nations High Commissioner for Voluntary counseling and testing World Health Organization IV

ABS'fRACT This study which will be a descriptive cross-sectional study aimed at describing knowledge, attitude and practice of post exposure prophylaxis among clinical dental students and clinical staff at dental school and clinical staff at Kenyatta hospital dental unit. The study will be conducted during the period between August and November 2009, the study population will be dental health workers and clinical students from the university of Nairobi dental school. Data will be collected by way of a self administered questionnaire. All inclusive for clinical students and dentists and Simple stratified random sampling method for nurses will be used to select the sample group. Data will be analyzed and presented with the help of tables, graphs and charts.

1.0 INTRODUCTION 1.1 Background Information Approximately 3 million health care workers (HeWs) are exposed to blood borne viruses each year. More than 90%of acquired infections occur in lowincome countries, and most could be prevented. Blood has been implicated as the source of the exposure in nearly all occupationally acquired infections. Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose or mouth with the patient's blood. Developed countries have recognized the importance of knowledge, attitudes and safe practice among Hews. There are number of studies addressing the professional risk, knowledge, attitude and practice among Hews but such studies are lacking in developed countries. (1) The term post-exposure prophylaxis (PEP) is generally understood to mean the medical response given to prevent the transmission of blood-borne pathogens following a potential exposure to HIV. In the context of HIV, post-exposure prophylaxis refers to the set of services that are provided to manage the specific aspects of exposure to HIV and to help prevent HIV infection in a person exposed to the risk of getting infected by HIV. These services might comprise first aid, counseling including the assessment of risk of exposure to the Infection, IDV testing, and depending on the outcome of the exposure assessment, the prescription of a 28-day course of antiretroviral drugs, with appropriate support and follow-up. For the purposes of these guidelines on providing PEP, individuals sustain potential occupational exposure to HIV in the course of their work. However, the term occupational post-exposure prophylaxis should not be assumed to be solely related to health care. Other workers, such as Post-exposure prophylaxis may be administered to prevent infection after potential exposure to other viruses (such as hepatitis B with the injection of immunoglobulin and vaccine). Emergency rescue staff, waste-disposal workers, law enforcement personnel and fire-fighters, 2

May be exposed to blood and other potentially infectious body fluids while performing their work duties. Individuals can also face potential non occupational exposure to HIV outside the work setting. In these guidelines, this term predominantly refers to potential exposure through sexual assault. Other forms of potential non-occupational exposure include those arising from needle-sharing among injecting drug users and potential exposure through consensual sex. (2) The exposed person is the person who has been potentially at risk of acquiring Hl V infection through exposure to blood or body fluids in his or her occupation or in another non-occupational situation. The source person is the person who is (either identified or not identified as) the possible source of contamination through potentially infectious blood or body fluid. If the serostatus of the source person is unknown, he or she may be asked to provide informed consent to HIV testing. The source person may be a patient if a health care worker is exposed or the perpetrator in sexual - assault. Worldwide, in 2007, an estimated 33.2 million people were infected with HIV. Post-exposure prophylaxis, which by defmition includes the prevention of mother-to-child transmission, is currently the only way of reducing the risk of development of Hl V infection in an individual who has been exposed to the virus, and as such, is widely considered to be an integral part of the overall strategy for preventing the transmission of HIV. Strong ethical arguments support providing PEP for HIV infection. Each day, thousands of people around the world experience accidental exposure to blood and other body fluids or tissues while performing their work duties. Health care workers are especially vulnerable( 1). Moreover, in many parts of the world, the potential for workplace accidents that may expose workers to HIV -infected blood and other body fluids is increasing. Several factors are contributing to the increased risk of occupational HIV exposure. At the same time, antiretroviral medicines are becoming increasingly available for treating AIDS, including in many resource-constrained settings, 3

with the result that more people with my are coming into contact with health care services. Second, as people receiving antiretroviral therapy accrue its benefits and live longer, they are more likely to survive, and the numbers of people living with HIY in contact with health services is increasing, both as health care providers and as people receiving treatment. Given that sexual exposure is associated with the risk of HIY transmission, there are also ethical reasons to support providing PEP to people who have been sexually assaulted. Although data on the efficacy of my PEP are fairly limited, good evidence suggests that a short course of antiretroviral therapy effectively reduces my transmission rates following needle stick exposure. This comes largely from a single case-control study involving health care workers (3) from France, the United Kingdom and the United States of America that revealed a strong inverse association between the likelihood of my infection following a needle stick injury and the post exposure use of zidovudine(2). Several case reports and cohort studies3 document some failures of PEP to prevent my infection. However, the above-mentioned zidovudine study did much to focus attention on the possible application of Hl'V PEP to exposure in other settings (such as for sexual exposure and occupational exposure among non-health care workers) and to raise questions about the feasibility, safety and cost-effectiveness of providing PEP generally. Moreover, international interest in using antiretroviral therapy to prevent my transmission following -sexual and other non-occupational exposure continues to grow, although there is no direct evidence of its efficacy in such contexts. Indirect evidence - that is, the results of animal studies and studies involving occupational exposure and mother-to-child transmission - nevertheless supports its biological plausibility. Prospective, randomized studies to evaluate the efficacy of PEP in preventing my are unlikely to ever be conducted because the generally supportive data described above create difficulty in withholding PEP for ethical reasons. In addition, evaluating the efficacy of an intervention aimed at reducing the risk of single incidents of exposure associated with low-risk transmission would require an extremely large sample size. 4

PEP may never be considered 100% effective. It is therefore imperative that HIV post-exposure prophylaxis policies reinforce the importance of primary prevention and risk prevention counseling in all settings where HIV could be transmitted. PEP should never be provided in isolation, but should always form a part of a wider strategy for preventing exposure to HIV. It is also associated with measures to prevent other blood borne diseases, such as hepatitis B and C. 2.0 LITERATURE REVIEW There have been several studies carried out on health care workers about PEP but none on dentists in specific. The only study carried out in Kenya was in thika district done by: M. Taegtmeyer at al the objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district,. Results showed that HCWs had the same HfV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence ofnsis was 0.97 per healthcare worker per year. Twenty-one percent had an HIV test in the last year. After one year there was a significant drop in the number of NSIs and a significant increase in the number of HCWs accessing Hl'V testing In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear ofhiv testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number ofnsis. Postexposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited particularly in the initial phases of a programme. (4) The other significant studies was Risk perception and attitudes towards Hl V in Serbian health care workers being the most outstanding carried out by Aleksandra Jovic-Vranes l et al it was based on Health care workers 5

(HCWs) at risk of occupational exposure to human immunodeficiency virus (HIV).(5) Its Aim was to investigate the perception of professional risk from, and the knowledge, attitudes and practice of HCWs to HfV and AIDS in Serbia. Done by a Cross-sectional study of 1559 Serbian HCWs using selfadministered anonymous questionnaires. Its Results were Eighty-nine per cent of HCWs believed that they were at risk of acquiring Hl V through occupational exposure. The perception of professional risk was higher among HCWs frequently exposed to patients' blood and body fluids, who used additional personal protection if the HfV status of patient was known (OR The majority of respondents had deficient knowledge about modes of Hl V transmission. Attitudes towards III V-positive patients were significantly different by occupation. Seventy per cent of HCWs used appropriate protection during their daily work with patients. Conclusion was HCWs require specific educational programmes and training protocols to ensure that they are adequately protected when carrying out high quality care.(5) 3.0 STATEMENT OF RESEARCH PROBLEM, JUSTIFICATION AND OBJECTIVES. 3.1PROBLEM STATEMENT Hl V and Aids is spreading at alarming rate and the fact that the number of medical practioners getting it from needle stick injuries is on the rise at extraordinary proportion (2). The lack of knowledge and practice about PEP is real and health care workers do not seem to know how important it is in the prevention of Hl V. The safety of healthcare workers is becoming important especially in developing countries. This is due to lack of resources and importance of functioning health sector in society required for development. 6

3.2 JUSTIFICATION OF THE STUDY This study is aimed at acquiring data on pep usage as in my experience I see a lot of health care workers are not aware of pep. Hence this study tries to find out the knowledge attitude and practice of post exposure prophylaxis by students and clinical staff at dental school, This will help to protect our healthcare workers following exposure to HIV and other diseases which in turn will help our country fight the war against HIV and secure the lives of health care workers in particular that of dentists. 3.3 OBJECTIVES 3.31 GENERAL OBJETIVES To determine knowledge attitude and practice towards post exposure prophylaxis among clinical dental students and clinical staff at dental school and at Kenyatta hospital dental unit. 3.32 SPECIFIC OBJECTIVES To explore the incidence of needle stick injuries To explain how the needle pricks are handled in the two institutions. To find out the adherence of PEP ARVS as a result of needle stick injuries by the clinical health workers in the two institutions. To know the knowledge of ARV PEP among the clinical health workers in the two institutions. 7

4.0 METHODOLOGY 4.1 STUDY AREA Nairobi university dental hospital is a teaching hospital which is located opposite Nairobi hospital doctor's plaza and lee funeral home. When started it was the 1st teaching hospital for dentistry and is the largest in Kenya. It provides treatment of all dental conditions with sirength in the number of highly trained teaching staff. It is located in Nairobi which is the economic and political capital of Kenya it also is a multicultural place with a population of 5 million residents. 4.2 STUDY POPULATION The study population will be dental Students and clinical Staff at Dental School. 4.3 STUDY DESIGN This is going to be a Descriptive cross sectional study 4.4 VARIABLES 4.41 DEPENDENT VARIABLES 1. Knowledge on pep 2. Attitude of pep 3. Practice of pep 4. Needle prick injury. 5. Time pricked 6. Completion of dose 7. Site of injury 4.42 INDEPENDENT VARIABLES 1. age 2. sex 3. category student dentist nurse 8

4.5 SAMPLING 4.51 SAMPLING UNIT The sampling unit will be dental Student and clinical School of University Of Nairobi. Staff at Dental 4.52 SAMPLING METHOD Simple stratified random sampling method will be used to select subjects from the clinical staff (nurse) sample size and it there will be an all inclusive for the dental students and lecturers.. 4.53 SAMPLE SIZE DETERMINATION A prevalence rate of 50% will be used in the study, since similar studies have not shown any prevalence rate. Sample size Where: N Study population Z value is 1.96 P Prevalence is 50% (0.5) C Confidence level of95% (0.95) N = (1.96)20.5(1-0.5) (1-0.95)2 N=384 9

Since the population is less than 10000 nf=n l+n N nf= 384 = 154 1+ 384 200 Where nf=desired sample size for a population less than 10000 n= sample size for a population greater than 10000 N= estimate size of population within the institution Therefore 154 dental health workers from the institution will participate in the study 4.54 DATA COLLECTION TOOLS A Self administered questionnaire will be used. 4.6 INCLUSION AND EXCLUSION CRITERIA 7.61 INCLUSION CRITERIA 1. All clinical Dental students and health care workers who are in dental school. 4.62 EXCLUSION CRITERIA 1. All NON clinical Dental students and NON clinical health care workers who are in dental school. 4.7 ETHICAL CONSIDERATIONS 1. Ethical clearance will be obtained from the university of Nairobi standards and ethics committee. 2. Written permissions to conduct the study will be obtained from the university of Nairobi standards and ethics committee. 3. Informed consent will be obtained from the participants of the study 10

4. Information will be regarded as confidential and will not be revealed to third parties information will only be used for the purpose of the study. 5. Participants will be allowed to terminate their consent without victimization during the period of the study. 4.8 MINIMIZATION OF ERRORS AND BIAS 1. There will be pre testing of the questionnaire. 2. Accurate analysis to ensure accurate interpretation of the results. 3. Uniformity in data collection. 5.0 EXPECTED BENEFITS 1. Establishment of specific data concerning dentists In Kenya relating to risks of occupational exposure. 2. Use of results in future policy making 3. Use of research in educating staff and students of the risks at work 4. Helps students with knowledge of benefits and downfalls of PEP. 11

6.0 PROPOSED BUDGET ITEM NUMBER OF UNIT COST TOTAL COST UNITS kshs kshs PROPOSAL DEVELOPMENT Browsing cost 6hrs 120 720 Stationary 60 10 600 Printing 100 5 500 Miscellaneous cost 500 DATA COLLECTION Transport and 25 20 500 communication Data collection and 1000 analysis Binding 900 PROJECT REPORT COMPILATION Draft Research Project 400 Final report 400 Stationary 40 10 400 Typing printing and.. 1200 bindinz Miscellaneous cost 500 GRAND TOTAL 7620 12

7.0 REFERENCES 1. The burden of disease from sharps injuries to health-care workers at national and local levels. Geneva, World Health Organization, 2005 (WHO Environmental Burden of Disease Series, No. 11; 2. Dlvl Cardo et al. Case-control study ofhiv seroconversion in health-care workers afterpercutaneous exposure to HIV-infected blood - France, U.K. and U.S., Jan. 1988-Aug 1994. Morbidity and Mortality Weekly Report (MMWR), 1995,44: 929-933 or New England Journal of Medicine, 1997,337:1485-1490. 3. Garcia M et al. Post-exposure prophylaxis after sexual assaults: a rospective cohort study. Sexually Transmitted Diseases, 2005, 32:214-219. 4. An ILO code of practice on illy/aids and the world of work. Geneva, International Labour Organization, 2001 5. United Nations General Assembly. Convention on the Rights of the Child. Geneva, Office of the United Nations High Commissioner for Human Rights, 1990 (http://www.unhchr.ch/ html/menu31b!k2crc.htm, accessed 2 November 2007). 6. Lii FX, Jacobson RS. Oral mucosal immunity and HIV/SIV infection. Journal of Dental Research, 2007, 86:216-226. 7. Kumar RB et al. Expression of HIV receptors, alternate receptors and coreceptors tonsillar epithelium: implications for HIV binding and primary oral infection. Virology Journal, 2006,3:25. 13

APPENDIX 1 Questionnaire Instructions Please fill this questionnaire concerning knowledge attitude and practice of Post Exposure Prophylaxis. The participation in this study is voluntary and any information that you provide will remain strictly confidential. Please fill appropriately. 1. Sex: 1) Male 2) Female 2. Category of respondent: 1) Dentist 2) Student 3) Nurse 3. If student, which year of university study are you in? 1) III 2) IV Knowledge 4. Have you ever heard of Post Exposure Prophylaxis (PEP)? 1) Yes 2) No 5. If yes, please state briefly what it is? 6. Is there a protocol of PEP in your institution? 1) Yes 2) No 7. If yes, please state it? 8. Have you ever had a needle stick injury at your place of work? 1) Yes 2) No 9. Have you ever had a blood splash (aerosol) at your place of work? 1) Yes 2) No 14

Attitude 10. If yes to number 6 and 7, were you given PEP or did you take PEP? 1) Yes 2) No 11. How long was PEP given to you? 1) 28 days 2) 14days 3) 7 days 12. Did you finish the dose? 1) Yes 2) No 13. If no, please state why? 14. Please state where on your body were you pricked? Practice 15. Do you think pep is helpful? 1) Yes 2) No 16. Do you know where you can get pep if you need it? 15

APPENDIX 2 CONSENT FORM I am sahil popat, a level III bachelor of dental Surgery student in the University of Nairobi. I am currently conducting a research concerning knowledge attitude and practice of Post Exposure Prophylaxis by clinical students and clinical staff at School of Dental Sciences, University of Nairobi. Participation is voluntary and utmost confidentiality is assured. Your participation in this study will be highly appreciated. I. do hereby willfully give consent to participate in this study. Sign. Date. 16