VACCINATION STATUS AGAINST HEPATITIS B AMONG DOCTORS OF AYUB TEACHING HOSPITAL, ABBOTTABAD. Homo sapiens

VACCINATION STATUS AGAINST HEPATITIS B AMONG DOCTORS OF AYUB TEACHING HOSPITAL, ABBOTTABADResearch project report submittedto theDepartment of community medicineAyub medical college AbbottabadByRUKHSANA SHAHEENRoll NO. 12-160Batch – HSupervisorAsst. Prof . Dr. Ashfaq Ahmad.2016AYUB MEDICAL COLLEGE ABBOTTABADSUPERVISOR’S CERTIFICATEI, hereby, certify that Rukhsana Shaheen, Roll.No.12-160 has successfully completed her research project entitled Vaccination Status among Doctors working at Ayub Teaching Hospital Abbottabad”. She has been working under my supervision. The enclosed Report is prepared according to the Departmental guidelines. I have read the thesis and have found it satisfactory as per requirements of the department.SIGNATURE OF SUPERVISOR _____________________________DEPARTMENT STAMP _____________________________NAME OF SUPERVISOR: Associate Professor Dr. Ashfaq AhmadACKNOWLEDGMENTI wish to express my sincere thanks to Department of community medicine. Ayub medical college Abbottabad for providing participation in such activity, and providing me with all necessary facilities for the research.I want to grant gratitude to all my respected teachers for their valuable lectures regarding research methodology. I wish special thanks to Asst. Prof. Dr. Ashfaq Ahmed for his timely guidance in the conduct of our project. I am also thankful to Dr. Huma Jadoon, Assoc. Prof. Dr. SaleemWazir, Assoc. Prof. Dr. Umar farooq and all other faculty member of department for guiding us throughout this project. I am grateful to the doctors of Ayub teaching hospital for their cooperation during data collection.Rukhsana Shaheen12-1604th Year MBBSAyub Medical College, Abbottabad.LIST OF ABBREVIATIONSATH: Ayub Teaching HospitalHBV: Hepatitis B VirusHCW: Health Care WorkersWHO: World Health OrganizationHCC: Hepatocellular CarcinomaHBsAg: Hepatitis B Surface AntigenTABLE OF CONTENTSSUPERVISOR’S CERTIFICATE iACKNOWLEDGMENT iiLIST OF ABBREVATIONS iiiTABLE OF CONTENTS ivLIST OF TABLES vLIST OF FIGURE vAbstract: 1Introduction: 2Literature review: 4Objectives: 8Operational definitions: 8Study methodology: 9RESULTS: 10Discussion: 25Conclusion: 26Recommendations: 26Study limitation: 26References: 27Annex-I (Questionnaire) 30LIST OF TABLESTable 01: Genderwise distribution of ageTable 1:Ward wise distibution of Doctors 9Table 2: Duration of medical practice of doctors in ATH 10Table 3: Designation of doctors 11Table 4: Vaccination status in male and female doctors 12Table 5: Vaccination status in the different categories of doctors 13Table 6: Vaccination status with regard to risk of HBV infection to doctors 14Table 7: Vaccination status in doctors having needle stick or cutting injury 14Table 8: Vaccination status in doctors coming in contact with hepatitis B positive patients…………………..Table 9: Reason for vaccination…………………………………………………………………………………………………………..Table 10: Reason for non-vaccination………………………………………………………………………………Table 11: Opinion of doctors regarding HBV vaccination whether it should be made mandatory for doctors or not……………………………………………………………………………………………………………………………………LIST OF FIGUREFigure 1 Age wise distribution of doctors 9Figure 2: Gender of doctors 10Figure 3: Marital status 11Figure 4: Area of residence 12Figure 5:Percentage of doctors showing risk of HBV infection 13Figure 6: Percentage of doctors showing whether they have inflicted needle stick injury or not 14Figure 7: Percentage of doctors showing contact with HBV positive patients………………………………………Figure 8: Vaccination against HBV…………………………………………………………………………………………………….Figure 9: Frequency of HBV vaccine doses received by doctors……………………………………….............Figure 10: Frequency of doctors regarding screening for HBV infection…………………………………………Figure 11: Percentage of doctors showing their intention to HBV vaccination………………………………Abstract:Background:Hepatitis B is a major health problem for doctors all over the world, which is preventable by vaccination against HBV infection. Our study was conducted to assess the vaccination status of doctors working at Ayub Teaching Hospital and the possible reasons of vaccination and non vaccination.Methods:It was a cross sectional study conducted in different wards at Ayub Teaching Hospital Abbottabad, from December 2015 to June 2016. Non probability (convenient sampling) technique was used. Self administered questionnaire was used as a tool for data collection and then it was analysed using SPSS version 16 software. Finally results were represented in the form of tables and figures.Results:Our study included 124 doctors of varying ages, ranged from 25-55 years. 75% of the doctors were fully or partially immunised while 24% were non immunised. The main reason of vaccination (59%) was that the doctors considered themselves being at risk of getting HBV infection while the main reason for non immunisation (33%) was carelessness on the part of the doctors. Vaccination coverage of female doctors was higher than male.Conclusion:Hepatitis B vaccination status of doctors included in our study was high. Maximum doctors were fully immunised and the reason was high risk of infection. Few doctors were non vaccinated because of their carelessness.Keywords:Hepatitis B, Healthcare workers, and vaccination.Introduction:Hepatitis B is an infection in which there is inflammation of liver, caused by hepatitis B virus. It is the 10th leading cause of death worldwide being responsible for cirrhosis and carcinoma of the liver.1 Hepatitis B virus (HBV) with only human reservoir is a worldwide health problem causing liver failure and hepatocellular carcinoma in chronic stages. It is also an important cause of morbidity and mortality among chronic carriers. HBV infections are estimated to be the cause of 30% of liver cirrhosis and 53% of cancer in the world. 15-40% of patients with HBV infections develop cirrhosis, end stage liver failure, and hepatocellular carcinoma in life time.2Hepatitis B is a blood born infection so is common among patients who have undergone blood transfusions, tissue grafts, and health care workers who get needle prick injuries during treatment of a patient. It is also present in saliva and blood of an infected patient so is a major concern in dental care procedures.3 HBV infection has different clinical manifestations depending upon patient`s age infection and immune status of the patient. During incubation phase of disease, patient feels unwell with nausea, vomiting, diarrhoea, headache, low grade fever, and loss of appetite. Sometimes patients become jaundiced as well.4According to the World Health Organisation (WHO), two billion people have been infected with HBV of which 240 million are chronically infected and more than 3500000 people die from HBV infection. Pakistan is the most effected country for HBV infection after Egypt.5 According to Pakistan medical research council Baluchistan has highest prevalence of carrier rate of 4.3% while Khyber Pakhtoonkhwa (KPK) has lowest of 1.3%. In KPK high prevalence was seen in upper Dir 5%.6 Doctors, health care workers, and paramedics are all at increased risk of occupational acquisition of HBV infections, due to accidental injuries with needle. According to hepatitis B branch of centres for disease control, 500-600 workers get exposure to blood products are hospitalized annually.7 Nurses and technicians are at great risk of HBV infections because they interact directly with infected patients. Prevalence of HBV might be associated with low socio-economic status as it is the disease of poverty.8 HBV infections attributable to sharp injuries are converted to deaths which occur because of acute hepatitis, and end stage liver disease.9Pakistan Expanded Programme on Immunization (EPI) schedule involves administrating three doses of hepatitis B vaccines at six, ten, and fourteen weeks of age. In Pakistan children receive vaccination through EPI at fixed primary health centres. Immunization coverage rate in our country remain low with 59-73% of child aged 12-23 months receiving all three doses of hepatitis B vaccines.10Our study is based on the objectives to assess the vaccination status of doctors of Ayub Teaching Hospital Abbottabad, against hepatitis B infection and to assess the knowledge and attitude of doctors with regard to hepatitis B infection and its immunization.Literature review:The major liver diseases are hepatitis, hepatic failure, cirrhosis, portal hypertension, and cholestasis. The term hepatitis means inflammation of liver and is generally applied to all forms of diseases and injuries of liver associated with inflammation and scarring. It has two forms acute and chronic hepatitis distinguished by their duration and pattern of injury. It is classified on the basis of virus causing injuries such as hepatitis A, B, C, D. Apart from viruses it can also be caused by drugs, toxins, and other autoimmune diseases.11 Hepatitis B is an acute systemic infection with major pathology in liver, caused by HBV and transmitted usually by parental route. Usually it is an acute self limiting infection, which may be either subclinical or symptomatic. 12Virology of HBV:Hepatitis B virus is a double stranded DNA enveloped virus measuring 42-47nm in diameter with an icosahedra nucleocapsid. It is primarily a hepatovirus that replicates only in liver cells and detected in bile duct, epithelial cells, peripheral blood mononuclear cells, and in the cells of pancreas and kidney, but evidence for viral replication in these cells is controversial.13Mode of transmission:HBV is present in blood, saliva, semen, vaginal secretions, and menstrual blood and to a lesser amount in perspiration, breast milk, tears and urine of an infected person. It is resistant to breakdown so can survive outside body and is easily transmitted by contact with body fluids. The most common route of transmission is prenatal and is transferred during preschool year.Use of unhygienic injections and contaminated needles are also a common route of transmission in developing countries. it is also acquired by horizontal transmission in adult life i.e. through intravenous drug or sexual contact .other sources include blood transfusion, contaminated surgical instruments and donor organs.14 Hepatitis B e antigen positive mothers transmit the infection perinatally or via horizontal route to their immediate family members.15Risk factors:Hepatitis B has wide spectrum of risk factors which include blood or blood products of an infected person, infected pregnant mother, health care workers, intravenous drugs, use of unsterile surgical and dental instruments, tattooing, travelling to hepatitis B endemic areas, haemodialysis, heterosexuality and human immunodeficiency virus infections. Lack of vaccination among doctors, dentists, hospital personals is also a risk factor. Endoscopy, major surgery and tattooing cause major risk factors for developing chronic hepatitis B infections.16 it is documented that 10-20% injuries occurred while recapping a used needle so recapping is prohibited in some countries.17 In Pakistan females are more prone to HBV infections due to traditional methods of conducting deliveries. 18Pathogenesis:HBV integrates into host DNA and starts expressing oncogenic viral proteins and immune mediated hepatitis. Hepatocellular carcinoma and other tumours associated with HBV infections contain integrated DNA and micro deletions in their cellular DNA, which disturbs cellular growth control mechanisms. In addition to integration certain viral proteins may directly cause HCC, as they interfere with numerous transcription factors such as tumour suppresser gene, p53 gene, activating transcription factor-3, early growth response-1 and octamer binding protein. Thus viral products cause hepatocarcinogenesis by their ability to activate various cellular promoters.19Signs and symptoms:After exposure to HBV incubation period prolongs for 90 days. Symptoms appear as anorexia, yellow skin, malaise, fever, nausea and abdominal tenderness. Fullness in the right upper abdominal quadrant is also felt. Hepatomegaly occurs in infected children. Patient feels better for a day or two, finally jaundice appears. Urine becomes dark, faeces become pale and finally recovery takes place within 4-6 weeks. The disease also express in three ways, acute, chronic or fulminating. Most cases are acute with full recovery. The lesions seen in the liver damage during acute form include lymphoid cell infiltration, mild necrosis of liver parenchymal cells and proliferation of liver macrophages, the kupffer cells.20Complications:A number of HBV patients with chronic hepatitis will develop hepatocellular carcinoma, which is responsible for 90% of primary malignant tumours of liver seen in adults. Liver cancer is the 8th leading cancer in the world, which causes more than 500,000 deaths annually throughout the world. fulminant hepatitis B is a rare condition develops in 1% cases. It is caused by massive necrosis of liver substance and is usually fatal. Survival in adults is uncommon and in 20% patients extra hepatic manifestations are seen such as serum sickness, polyartiritisnodosa, membranous glomerulonephritis and papularacrodermetitis of childhood. Hepatitis delta virus is the only virus which becomes infectious in the presence of active HBV infection causing fulminant hepatitis.4A study was conducted to evaluate the information about feelings and habits of a person with chronic hepatitis B infection and related issues. More than 50% were anxious of spreading the disease to their family and 33% were nervous to disclose their identification to other people.21Diagnosis:The specimen of choice for diagnosis of HBV infection is blood. Serological tests for viral antigen and antibodies are used for diagnostic screening, and are performed on serum or plasma. There are two types of tests to monitor HBV infections, primary and secondary tests. If hepatitis s antigen (HsAg) is negative, there will be no evidence of active HBV infections. If HsAg is positive, there will be evidence of acute or chronic infections. If positive for more than six months infection will be chronic. Serum alanine Aminotransferase (ALT) is a marker of hepatitis B, because it is elevated in liver inflammation.22Treatment:Drugs available for hepatitis B infection in Pakistan are Lamivudine, Adefovir, Entacavir, Telbivudine, Pegylated interferon and Tthymosintenofovir. Tenofovir is a potent drug with low rate of resistance so is preferred over Adefovir. Pegylated interferon is given for one year in patients with fully compensated liver disease and contraindicated in patient with decompensated disease. Serum ALT and quantitative HBV DNA levels should be checked at three to six months after initiation of therapy, to determine response to treatment.23Prevention:Effective hepatitis B vaccines containing inactivated HbsAg have been available since 1980s. It is administered greater using a three dose schedule and its efficacy is greater in infants, children, and young adults. After WHOs, recommendation all the countries introduce universal HBV vaccination into their immunization programme. In addition risk of its transmission is also reduced through routine testing of blood, organs, and tissue donors, screening of blood and blood products, Use of condom to reduce sexual transmission.24 Immune prophylaxis with hepatitis B immunoglobulins has shown significant protection against intrauterine infections when administered to a pregnant lady during late pregnancy.25 Proper hand washing and use of gloves, gowns, and masks are main components of precautions which minimize mucocutaneouse exposure. The use of puncture resistant container for sharp disposal is also an effective strategy.26 Immunization with hepatitis B vaccine is the most effective means of preventing hepatitis B infections. The recommended strategy for preventing this infection is selective vaccination of persons with identifiable risk factors at any age. 27Objectives:1). To determine the vaccination status of doctors of Ayub teaching hospital Abbottabad.2). To determine the reason of vaccination and possible reasons of non vaccination.Operational definitions:1. Vaccination status: it will be determined by asking the doctors about their vaccination against Hepatitis B.Study methodology:Study design: cross sectional study.Setting: different wards of Ayub Teaching Hospital, Abbottabad.Duration: from December 2015 to June 2016.Study population: all the doctors of Ayub Teaching Hospital, Abbottabad.Sample size: 124.Sampling technique:non probability (convenient sampling).Sample selection: all the doctors of Ayub Teaching Hospital were included in the study except house officers, as they are not regular employees.Ethical consideration: the purpose and procedure to fill the questionnaire were explained to the doctors, before handling over them.Data collection: a self administered questionnaire was used as a tool for data collection.Data analysis: the data after collection and assembling is analysed using SPSS version 16. Quantitative variables were described in mean and standard deviation while categorical variables were described in terms of frequency and percentages. Chi square test was applied for categorical variables and P value was calculated. P value of 0.05 or less than it means that, the results are not statistically significant. The data was presented in the form of figures and tables.RESULTS:Our study sample size was 124 (n=124).The data was collected by six students and was completed in a duration from 28 April to 20 May 2016. The minimum ageof doctors was 25 years and maximum 55 years with a mean of 32.97±6.962 years and mode was 28 years (Figure 1).Among 124, 73(59%) doctors were male while 51(41.1%) were female. (Figure 2)Table 1: Gender wise distribution of ageGender Frequency Percentages Mean age Standard deviationMales 73 58.9 32.77 7.549Females 51 41.1 31.08 5.956Total 124 100There were 73 (58.9%) males and 51 (41.1%) females in our sample. Mean ages of male doctors were 32.77±7.549 and mean ages of female doctor were 31.08± 5.956. However the difference in mean age is not statistically significant, P=0.18 (Table 1)Figure 2: Gender of DoctorsThe data was collected from different wards.(Table 1)Table 1: Ward wise distribution of doctorsWard Frequency PercentMedical ward 24 19.4Surgery ward 13 10.5Gynaecology ward 26 21.0Eye ward 8 6.5ENT ward 3 2.4Dentistry ward 17 13.7Neurosurgery ward 6 4.8Paediatrics ward 21 16.9Orthopaedics ward 6 4.8Total 124 100.0Most of the doctors had served for 3 years with mean duration of6.62±6.93 years.(Table 2)Table 2:Duration of medical practice of doctors in ATHDuration N Minimum Maximum Mean Std. DeviationDuration of medical practice in years 124 0.08 35.00 6.6254 6.93411124In our study 73 (58.9%) of the doctors were married, while 51 (41.1%) were unmarried and nobody was separated, widowed or divorced (figure 3).Figure 3: Marital statusAmong 124, 106 (85.5%) of the doctors were from urban areas while 18 (14.5%) were from rural areas (figure 4).Figure 4: Area of residenceThe data was collected from doctors havingdifferent designation including trainee medical officers, medical officers, junior registrar, senior registrar, assistant professors, associate professors and professors (table 3).Table 3: Designation of doctorsDesignation Frequency PercentTMO 82 66.1MO 11 8.9JR 6 4.8SR 7 5.6Assistant professor 11 8.9Associate professor 5 4.0Professor 2 1.6Total 124 100.0Out of 124, 116 (93.5%) of doctors considered themselves being at risk of HBV infection, 6 (4.8%) considered themselves safe whereas 2 (1.6%) doctors didn’t know whether they are at risk or not(Figure 5).Figure 5: Percentages of doctors showing risk of HBV infection. (Yes=at risk, No=not at risk,don’t know= not aware whether at risk or not)Figure 6: Percentages of doctors showing whether they had needle cutting injuries or not.101 (81.5%) of the doctors had experienced needle stick injury during their medical practice, 17(13.7%) doctors replied that they have no history of injuries and 6 (4.8%) didn’t remember (Figure 6).Figure 7: Percentages showing doctors’ contact with HBV positive patients (Yes= came in contact, No= no contact, don’t know= not aware of contact)During medical practice 118 (95.2%) of the doctors had come in contact,5 (4%) didn’t come in contact while 1 (0.8%) didn’t know about their contact with HBV infected patients (Figure 7).Figure 8: Vaccination against HBV (Yes=vaccinated, no= not vaccinated)Among 124, 94(75%) doctors were vaccinated against HBV while 30(24%) were non vaccinated. figure 8When gender wise vaccination status was taken into account,more females were vaccinated as compared to male doctors (table 4).However the results are not statistically significant(P=0.15).Table 4:Vaccination status in the male and female doctorsGender doctor vaccination against HBV TotalYes NoMale 52 21 73female 42 9 51Total 94 30 124Vaccination status in different categories of doctors is given in table 5. The results are statistically significant(P=0.05).Table 5:Vaccination status in the different categories of doctorsDesignation of doctor doctor vaccination against HBV TotalYes NoTMO 57 25 82MO 11 0 11JR 3 3 6SR 7 0 7Assistant professor 9 2 11Associate professor 5 0 5Professor 2 0 2Total 94 30 12428 doctors who considered themselves being at risk of HBV infection had not vaccinated against it which shows their attitude toward HBV vaccination (table 6).However the results are not statistically significant (P=0.63).Table 6: Vaccination status with regard torisk of HBV infection to doctorRisk of HBV infection doctor vaccination against HBV TotalYes NoYes 88 28 116No 5 1 6Don’t know 1 1 2Total 94 30 124Similarly 23 out of 101 doctors who had experienced needle stick injury had not vaccinated against HBV (table 7).But the results are not statistically significant(P=0.48).Table 7: Vaccination status in doctors having needle stick or cutting injuryNeedle stick or cutting injury to doctor doctor vaccination against HBV TotalYes NoYes 78 23 101No 11 6 17Don’t know 5 1 6Total 94 30 124If we considered vaccination status of those doctors who had come into contact with HBV infected patients we see that 29 out of 89 doctors have not done their vaccination for HBV (table 8) P=0.82Table 8:Vaccination status in doctors coming in contact with HBV positive patientsContact with HBV infected person doctor vaccination against HBV TotalYes NoYes 89 29 118No 4 1 5don’t know 1 0 1Total 94 30 1246 (4.8%) doctors had received 1 dose, 14 (11.3%) had received 2 doses, and 52 (41.9%)had received 3 doses of vaccine.Most of the doctors 22 (17.7%) hadthree doses vaccination (figure 9).Figure 9: Frequency of HBV vaccine doses received by doctorsReasons given by doctors for their vaccination is given in table 9. The most common reason was that they considered themselves at high risk of getting HBV infection.Table 9:Reasons for vaccinationReasons Frequency PercentNo specific reason 2 1.6At high risk of HBV infection 56 45.2To protect myself from HBV 31 25.0Part of EPI programme 5 4.0Total 124 100.0The reasons given for non vaccination are given in (table 10). The most common reason being the carelessness.Table 10: Reasons for non vaccination.Reasons Frequency PercentNo special reason 4 3.2Shortage of time 8 6.5Carelessness 10 8.1Non availability of vaccine 5 4.0Never felt need 3 2.4Total 124 100.0Among non vaccinated 19 (63.33%) of the doctors had screened themselves while 11(36.66%) doctors had not screened themselves for HBV infection (figure 10).Figure 10: Frequency of doctors regarding screening for HBV infectionAmong non vaccinated 29 (96.66%) of the doctors had intented to vaccinate themselves in near future while 1 (3.33%) doctor didn’t want to vaccinate (figure 11)Figure 11: Percentages of doctors showing their intention to HBV vaccinationAccording to 123 (99.2%) of the doctors hepatitis B vaccination should be made mandatory for doctors while only 1(0.8%) gave no opinion (table 11).Table 11: Opinion of doctors regarding HBV vaccination whether it should be made mandatory for doctors or notOpinion Frequency PercentYes 123 99.2No comments 1 0.8Total 124 100.0Discussion:Hepatitis B is one of the major causes of morbidity and mortality throughout the world including Pakistan. There are about 31% cases of acute viral hepatitis, 60% cases of chronic liver disease, and 59% cases of hepatocellular carcinoma due to hepatitis B infection in Pakistan. According to estimation 100-200 HCW died annually in the past few decades due to HBV infection.30 Healthcare workers coming in contact with hepatitis B patients or infected blood are at high risk of getting the infection and vaccination has been generally recommended for them. The vaccines available are genetically engineered and give more than 90% protection, when used appropriately.28 According to our study which was conducted at Ayub Teaching Hospital on 124 doctors, 75% of the doctors are vaccinated against HBV, among them 71% are male while 82% are female and 25% doctors are unimmunized. A study conducted by Memon et al in Hyderabad on 923 doctors revealed that 64% of the doctors are vaccinated, among them 70% are male and 30% are female.29 This difference in results may be due to different sampling techniques.In our study 24%of the doctors are nonvaccinated against HBV and the most common reason is carelessness. A study conducted at Services Hospital Lahore on 215 doctors reported that 18% of the doctors were unimmunized and the most common reason was non availability of vaccines.7 Another study conducted by Qudus in Pakistan stated that out of 400 HCW, 28% are immunized and 24% are unimmunized and the reason being unaware of vaccines. 13 Similar study conducted at Hayat Shaheed Teaching Hospital Peshawar reported that 57% of doctors were nonvaccinated and reason was lack of motivation and financial constraints.28In a study conducted in tertiary care hospital Lahore, 60% of HCW are completely vaccinated, 18% were incompletely vaccinated, and 22% were non immunized. The reason for nonimmunisation was lack of motivation.30 These results are almost similar to our study results, and the probable reason of this similarity could be the similarity of demoghraphic profile.A study conducted in Agha khan Hospital Karachi, showed that 86% of the HCW were completely immunised. The reason for this difference is that in Agha khan Hospital, all the HCW who are in direct contact with the patients are, provided free of cost immunisation against hepatitis B.30 while Ayub teaching hospital donot have such facility, to provide free immunisation.Conclusion:It is concluded that 75% of the doctors of Ayub Teaching Hospital are vaccinated against Hepatitis B, which is a good percentage. 24% of the doctors who consider themselves being at risk of getting HBV infection are nonimmunised. 22% of the doctors had undergone needle stick injuries, and are nonimmunised. 24% came in contact with HBV infected person are also nonimmunised, which shows their negative attitude towards vaccination. The most common reason for nonimmunisation is carelessness of doctors.Recommendations:1. There should be campaigningto create awareness of HBV infection among doctors.2. Free of cost immunisation of doctors should be introduced in hospitals.3. Vaccination against HBV infection should be a prerequisite of jobs offered to doctors.4. HCW should be motivated for a behavioural change, to enhance their occupational safety.5. Antibody titre of immunised doctors should be checked to ensure their safety.Study limitation:We used non probability sampling technique and the assessment of vaccination status was subjective.Objectives:1). To determine the vaccination status of doctors of Ayub teaching hospital Abbottabad.2). To determine the reason of vaccination and possible reasons of non vaccination.Operational definitions:2. Vaccination status: it will be determined by asking the doctors about their vaccination against Hepatitis B.3. Those doctors who had 3 or more doses ofhepatitis B vaccine are considered as fully immunized against hepatitis B, while those who had 1 or 2 doses are considered as partially immunized, and those who are not vaccinated are considered nonimmunised.References:1. Shigri AA, Leghari MA, Mazher S, Bano M. 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Molecular epidemiology hepatitis B and C in Estonia. J Swedish institute Inf Dis 2008;3(7):1-726. Askarian M, Yadoullah M, Kouch F, Danai M. Precautions for health care workers to avoid HBV and HCV infections. J community medicine dept shiraz 2011;2(4):191-727. Khurum N, Khan AK, Kadri WM, Salim S, Aziz H. Hepatitis B vaccination among health care workers and students of medical college. J AllamaIqbal Med Coll 2008;8(6):1-828. Haq N, Rehman S, Khan PM, Afridi J, Wajid A, Afaq et al. Vaccination status against hepatitis B in doctors working at Hayat Shaheed Teaching Hospital Peshawar. J dept of medicine 1998;2(1):29-3229. Memon MS, Ansari S, Nizami R, Katri NV. Hepatitis B vaccination status in HCW of two university hospitals. J Lahore Uni manag health Sci 2007;3(6):48-5130. Sheikh NH, Hasnain S, Mahnoor A, Tariq M. Status of hepatitis B vaccination among HCW of a tertiary care hospital Lahore. J biomedical 2007;23(7)17-20Annex-I