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Year : 2004  |  Volume : 1  |  Issue : 1  |  Page : 229-239
HBV and Indian medical and dental students

Department of Gastroenterology, Biochemistry and Oral & Maxillofacial Surgery, S.C.B. Medical College, Cuttack 753 007, India

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How to cite this article:
Singh SP, Swain M, Kar IB. HBV and Indian medical and dental students. Hep B Annual 2004;1:229-39

How to cite this URL:
Singh SP, Swain M, Kar IB. HBV and Indian medical and dental students. Hep B Annual [serial online] 2004 [cited 2024 Feb 21];1:229-39. Available from: https://www.hepatitisbannual.org/text.asp?2004/1/1/229/27928

Hepatitis B is the most important infectious occupational hazard for Indian medical and dental students. The high risk of being infected is the consequence of the high prevalence of virus carriers in the assisted population, the high frequency of exposure to blood and other body fluids and the high contagiousness of hepatitis B virus (HBV). The infected victim not only suffers incalculable harm, but may sometimes also inadvertently transmit the infection to patients treated by him. Vaccination is able to prevent the most threatening consequences of the infection (acute disease and chronic carriage) in responders. Hence it is essential that steps should be taken at the earliest to protect the medical students from possible infection on the one hand, and to insulate the patients from the "infectious" physician on the other hand. It is essential that the medical fraternity must first come together to address the issues involved and come to a consensus, and then later influence the lawmakers to make suitable regulations or laws in this regard.


One of the most serious threats medical and dental students face during their clinical training is the possibility of exposure to blood-borne pathogens, with the attendant risk of infection with HIV, HBV or HCV.[1] Hepatitis B is the most important infectious occupational disease for medical students and health care workers. The high risk of being infected is the consequence of the high prevalence of virus carriers in the assisted population, the high frequency of exposure to blood and other body fluids and the high contagiousness of hepatitis B virus (HBV). The consequences of infection with hepatitis B virus are potentially fatal and include chronic liver disease, cirrhosis and primary hepatocellular carcinoma. Yet the problem of exposure to contaminated blood among the medical students has received inadequate attention, more so in India. The magnitude of the problem can be gauged from the fact that 4.4 million HCWs in the US receive approximately 800,000 needle sticks and other injuries from sharp objects annually.[1] An estimated 16,000 of these objects are contaminated with HIV, and even more are contaminated with HBV or HCV.[2] Medical students receive percutaneous injuries as often or more often than HCWs.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

48 % of all graduating medical students recalled being exposed at least once to potentially infectious body fluids during their last two years of medical school.[12] A recent American study revealed that 32.8 percent dental students reported experiencing occupational exposures (OEs) to blood or other potentially infectious materials. Of these, 39% reported two or more exposures each.[15]

Transmission is rare in persons who have been immunized. Transmission rate is as high as 30% among those who are not immune.[16] Infected medical students face daunting prospects including:[1]

  • Difficulties securing health insurance
  • Loss of income from their income and financial destitution
  • Long term disability
  • Premature death

The unfortunate medical students do not have either compensation coverage like workers or adequate health insurance arrangements.

What then should be done to take care of these serious issues?

  • The medical students should be properly trained as regards personal safety measures.
  • The Medical Colleges should provide adequate health and disability insurance.
  • Provision should be made by proper legislation for compensation to medical students like worker's compensation.

British medical students and the hepatitis B virus

In the United Kingdom, the Department of Health way back in 1993 issued guidance on hepatitis B, requiring all healthcare workers (including medical students) who perform exposure prone procedures to be vaccinated against hepatitis B and to have their serological response to the vaccine checked. As per the "Guidance", healthcare workers who perform invasive procedures and who do not respond to vaccination must be tested for hepatitis B carrier status. Those who are found to be positive for surface antigen without "e" markers (HBsAg positive and HBeAg negative) need not be excluded from any work. Workers who have "e" markers (HBeAg positive) should be excluded from invasive procedures. The Vice-chancellors and Principals of the Universities of the United Kingdom[17] came together to discuss the problem, and the CVCP finally in 1994 made an emotive decision. It decided that "the duty of care is paramount" and that "medical and dental students have an ethical duty to protect patients". It laid down guidelines for universities on the fitness of students to practise medicine. The CVCP announced that: "Successful applicants to Medical Schools must have proof of non-infectivity and immunisation against hepatitis B by the time of registration", and "students infectious for hepatitis B should be excluded from clinical course."

This was followed by an acrimonious debate on this issue. There was a lot of criticism of this policy from different corners including the BMA's Medical Students Committee, and demands were made for withdrawal of the policy.[18],[19],[20],[21] There was considerable support for the steps taken by the CVCP too.[22] A Lancet editorial emphasizing the virtues of the CVCP's ruling cited that it was better for the students to know about their hepatitis B status before embarking on an intensive course of study lasting five years or more. Despite the opposition, the guidelines were not relaxed, except that subsequently in 1995 the Committee of Vice-Chancellors and Principals of the Universities of the United Kingdom revised their 1994 ruling and came up with the following corrigendum: "Provided that that the student had been given vaccine, as appropriate, it was not necessary to show that he or she was immune." [23]

However this modified version of the recommendations was not fool proof. The CVCP 1995 revised guidance did not include or give indication of which markers of HBV infection were necessary to determine a student's infectivity or what antigenic status is incompatible with medical school entry. As expected, this resulted in different parameters being considered for the purpose of infectivity by the different medical schools in the United Kingdom. A survey of the policy adopted by the twenty seven British medical schools in this regard in 1995 revealed utter confusion. Two medical schools confused hepatitis B surface antibody and antigen, and would refuse a student who was antibody positive. Besides, five medical schools were prepared to reject students who were hepatitis B surface antigen, without consideration of "e" markers which goes much further than required by the NHS guidance.[24]

American medical students and HBV

An unofficial survey of medical school policies in several countries including Australasia, the USA and the Netherlands conducted by the Lancet showed more confusion than consensus! In the USA, questionnaire surveys of final year medical students are conducted annually by the Association of American Medical Colleges. Students are asked whether they have been vaccinated against hepatitis B. Nevertheless, medical schools do not routinely undertake serological screening before offering vaccination, and post vaccination testing is even less likely.[22]

However, there is no point in comparing India with U.S.A. because in America, before the child grows up to become a medical student, he goes through schools where hepatitis B vaccination is compulsory. The 1991 recommendation for universal infant vaccination with hepatitis B vaccine and state requirements for proof of vaccination at kindergarten entry produced a cohort of children in the United States who are highly vaccinated against hepatitis B. As of July 2001, of the 43 states with middle school vaccination laws, 27 required students entering middle school to be fully vaccinated against hepatitis B.[25]

HBV and the Indian medical students

India has a high prevalence of HBV carriers - much higher than that in the United States, Britain and other developed countries. As a consequence, it is obvious that the Indian medical students are likely to be exposed and to be at risk to get infected by the HB virus with much greater frequency than their Western counterparts. At New Delhi, a study was conducted involving 200 medical students regarding safety precautions observed while performing various invasive procedures during their clinical posting. Only 106 students responded with the completed questionnaire. The most common procedure performed by the students was drawing of blood, with an average frequency of 60.8 per month. Sixty-one per cent of the students reported being injured during the various procedures and only 35.5% of them used gloves. Resheathing the needle was responsible for causing injury to 69% of the students, which was significantly higher than injuries occurring while entry into the vein or withdrawing the needle (p<0.05).[26]

A study from New Delhi in 1997 revealed that while only 2.3% preclinical students were positive for HBsAg, and 18% and 10.4% for anti HBs and anti HBc respectively, amongst the clinical group who had been exposed to the clinical departments, the corresponding figures were 1.4%, 69% and 55% respectively; these figures clearly show how great is the risk of exposure to HBV infection during exposure to clinical departments.[27] Another study from Mumbai in 2002 highlighted the lack of awareness among medical and nursing students. Besides, the study also revealed that only 26.3% of the medical students had taken 3 doses of hepatitis B vaccination.[28] However, a study from Orissa in 2000 found that although the vaccination rate was 86.7% among dental students and 79.5% among medical students, it was an abysmal 1.9% among nursing students.[29] High cost of vaccination and lack of free vaccination programme were the reasons cited for non-vaccination in all but one nursing student. None of the students received counseling about hepatitis B vaccination at the time of admission to medical college. The investigators concluded that the vaccination rates among medical and dental students were suboptimal. However, the vaccination rate for nursing students were disproportionately low. They suggested that all students should be counseled about hepatitis B vaccination at the time of entry to medical schools and the vaccination should be offered free to all students who are not only at risk of acquiring HBV infection but may also be potential transmitters of this infection to their patients.[29]

From the available information it is now quite evident that although the Western Institutions have taken adequate steps to protect their medical students in their country despite the risk being too small, the Indian institutions including the statutory bodies like the Indian Medical Council (MCI), the University Grants Commission (UGC), and the Ministry of Health, and professional bodies like the Indian Medical Association (IMA), Indian Society of Gastroenterology (ISG), Indian Association for Study of the Liver (INASL) and the Association of Physicians of India (API) pretend to be blissfully ignorant of their duties and responsibilities in this regard. They have done precious little in this regard. The result is that once the hapless Indian medical student gets infected with this virus, he is left all alone to fend for himself.

Other SAARC countries

A report from a study in Lahore, Pakistan to assess the vaccination status among HCWs and medical students found that only 49% health care workers and 42.20% medical students were vaccinated. The main reasons for non-vaccination (47.7%) among health care workers was the high cost of vaccination, while the most often cited reason (33.7%) among medical student was the belief that they were not at risk. This belief was also prevalent among nurses (36.4%), laboratory workers (38.6%) and paramedics (33.2%). The authors concluded that in a low-income country like Pakistan, the health institutions should bear the cost for vaccinating their staff. Efforts should also be made to impart appropriate health education regarding hepatitis B infection. A study from Sri Lanka investigated the presence of HBV and HCV markers in new entrant medical students and found that none of them had been vaccinated against hepatitis B. At least one risk factor for hepatitis B or C was present in 32 (7%) of them. None of the samples were positive for HBsAg or anti-HCV, and only two (0.44%) were positive for anti-HBs. The investigators concluded that since most new entrant medical students were not immune to hepatitis B and C viral infections, there is a strong case to vaccinate medical students against hepatitis B before they were exposed to clinical work.

The HBV infected health care provider and the patient

A recent report once again highlights the grave risks faced by the patient who is treated by an infected health care provider. The report suggests that a surgeon with hepatitis B may have infected 28 of his patients with hepatitis B virus.[32]

In India, there are around 226 medical colleges with approximately 50,000 medical students. In India one shudders to think - in the absence of any regulation in this matter - How many unsuspecting medical students become infected with HBV and suffer? How many patients must be getting quietly infected by their treating doctors?


There is an urgent need for formulation of a national policy in these matters. While the medical students need to be protected from the dangerous hepatitis B virus, steps also need to be taken to protect the patients from being unwittingly infected from an infectious health care provider. An aggressive approach needs to be followed as regards vaccination of the medical students. Steps should be taken to provide for adequate compensation for the medical students. Besides this, there should also be provision for comprehensive health and disability insurance for the medical students.

  References Top

1.Tereskerz PM, Pearson RD, Jagger J. Occupational exposure to blood among medical students. N Engl J Med 1996:335:1150-3.  Back to cited text no. 1    
2.Jagger J, Pearson RD. Universal precautions: still missing the point on needlesticks. Infect Control Hosp Epidemiol 1991;12:211-3.  Back to cited text no. 2  [PUBMED]  
3.Tereskerz PM. Percutaneous injuries among medical students. Adv Exposure Prev 1995;1:10-2.   Back to cited text no. 3    
4.Gompertz S. Needle-stick injuries in medical students. J Soc Occup Med 1990;40:19-20.   Back to cited text no. 4  [PUBMED]  
5.deVries B, Cossart YE. Needlestick injury in medical students. Med J Aust 1994;160:398-400.   Back to cited text no. 5  [PUBMED]  
6.Kirkpatrick BL, Ricketts VE, Reeves DS, et al. Needlestick injuries among medical students. J Hosp Infect 1993;23:315-7.   Back to cited text no. 6  [PUBMED]  
7.Choudhury RP, Cleator SJ. An examination of needlestick injury rates, hepatitis B vaccination uptake and instruction on 'sharps' technique among medical students. J Hosp Infect 1992;22:143-8.   Back to cited text no. 7  [PUBMED]  
8.China HP, Koh D, Jeyaratnam J. A study of needle stick injuries among medical undergraduates. Ann Acad Med Singapore 1993;22:338-41.  Back to cited text no. 8    
9.O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch Intern Med 1992;152:1451-6.  Back to cited text no. 9    
10.Stotka JL, Wong ES, Williams DS, et al. An analysis of blood and body fluid exposures sustained by house officers, medical students, and nursing personnel in acute-care general medical wards: a prospective study. Infect Control Hosp Epidemiol 1991;12:583-90.  Back to cited text no. 10    
11.Waterman J, Jankowski R, Madan I. Under-reporting of needlestick injuries by medical students. J Hosp Infect 1994;26:149-50.  Back to cited text no. 11    
12.Koenig S, Chu J. Medical student exposure to blood and infectious body fluids. Am J Infect Control 1995;23:40-3.  Back to cited text no. 12    
13.Resnic FS, Noerdlinger MA. Occupational exposure among medical students and house staff at a New York City medical center. Arch Intern Med 1995;155:75-80.   Back to cited text no. 13    
14.Vergilio JA, Roberts RB, Davis JM. The risk of exposure of third-year surgical clerks to human immunodeficiency virus in the operating room. Arch Surg 1993;128:36-9.  Back to cited text no. 14    
15.Kotelchuck D, Murphy D, Younai F. Impact of Underreporting on the Management of Occupational Bloodborne Exposures in a Dental Teaching Environment. J Dent Educ 2004;68:614-22.  Back to cited text no. 15    
16.Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991;40:1-9.  Back to cited text no. 16    
17.Committee of Vice Chancellors and Principals of the Universities of the United Kingdom. Fitness to practice medicine and dentistry in relation to hepatitis B. London: CVCP, 1994.  Back to cited text no. 17    
18.Lever AML. Hepatitis B and medical student admission (editorial). BMJ 1994;308:870-1.  Back to cited text no. 18    
19.Gaunlett R, Bailey M. Hepatitis B and admission to medical school (letter). BMJ 1994;308:1161.  Back to cited text no. 19    
20.Lever AML. Hepatitis B and medical student (letter). BMJ 1994;308:1710-1.  Back to cited text no. 20    
21.Richards P. Harries F. Hepatitis B and admission to medical school. BMJ 1994;308:1161.  Back to cited text no. 21    
22.Entry to medical school : by examination and vaccination? (editorial) Lancet 1994;343:927-8.  Back to cited text no. 22    
23.Committee of Vice Chancellors and Principals of the Universities of the United Kingdom (CVCP). Guidance to fitness to practise: Hepatitis B. London : CVCP, 1995.  Back to cited text no. 23    
24.Parker G. Jenkins S. Hepatitis B and admission to medical school: an audit of British medical school policy. BMJ 1996;313:856-7.  Back to cited text no. 24    
25.CDC. Effectiveness of a Middle School Vaccination Law - California, 1999-2001. MMWR 2001:50;660-3.  Back to cited text no. 25    
26.Varma M, Mehta G. Needle stick injuries among medical students. J Indian Med Assoc 2000;98:436-8.  Back to cited text no. 26    
27.Khurana V, Kar P, Mansharamani N, et al. Differences in hepatitis B markers between clinical and preclinical health care personnel. Trop Gastroenterol 1997; 18:69-71.   Back to cited text no. 27    
28.Biju IK, Sattar A, Kate M, et al. Incidence and awareness of hepatitis B infection among medical and paramedical students. Indian J Gastroenterol 2002;21(Suppl 1):A104-5.  Back to cited text no. 28    
29.Singh SP, Mishra GC, Mittal AK, et al. Hepatitis B vaccination among medical, dental and nursing students at medical college: results of a survey. Indian J Gastroenterol 2000;19(Suppl 2):A33-4.  Back to cited text no. 29    
30.Nasir K, Khan KA, Kadri WM, et al. Hepatitis B vaccination among health care workers and students of a medical college. J Pak Med Assoc 2000;50: 239-43.  Back to cited text no. 30    
31.Premawardhena AP, Premaratne R, Jayaweera G, et al. Hepatitis B and C virus markers among new entrant medical students. Ceylon Med J 1999;44:120-2.  Back to cited text no. 31    
32.Spijkerman IJ, van Doorn LJ, Janssen MH, et al. Transmission of hepatitis B virus from a surgeon to his patients during high-risk and low-risk surgical procedures during 4 years. Infect Control Hosp Epidemiol 2002;23:306-12.  Back to cited text no. 32    

Correspondence Address:
Shivaram Prasad Singh
Department of Gastroenterology, Biochemistry and Oral & Maxillofacial Surgery, S.C.B. Medical College, Cuttack 753 007
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