
==== Front
BMC Infect Dis
BMC Infect Dis
BMC Infectious Diseases
1471-2334
BioMed Central London

9703
10.1186/s12879-024-09703-4
Research
Self-reported exposure to blood and body fluids and serological evidence of lifetime exposure to hepatitis B virus among health care workers in Ghana: a cross-sectional study
http://orcid.org/0000-0003-4360-4747
Senoo-Dogbey Vivian Efua efuvivi@yahoo.co.uk
vesenoo-dogbey@ug.edu.gh

12
http://orcid.org/0009-0009-7075-7782
Klutsey Ellen Eyi 3
1 https://ror.org/01r22mr83 grid.8652.9 0000 0004 1937 1485 Department of Public Health, School of Nursing and Midwifery, University of Ghana, P. O. Box LG 25, Accra, Legon Ghana
2 https://ror.org/04yexcn51 grid.442268.e 0000 0001 2183 7932 Ghana Institute of Management and Public Administration, Greenhill Campus Achimota, Accra, Ghana
3 https://ror.org/054tfvs49 grid.449729.5 0000 0004 7707 5975 Department of Nursing, University of Health and Allied Sciences, Ho, Volta Region Ghana
13 9 2024
13 9 2024
2024
24 96822 3 2024
1 8 2024
© The Author(s) 2024
2024
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Introduction

In Sub-Saharan Africa alone, about 40–65% of Hepatitis B Virus infections among HCWs were a result of percutaneous occupational exposures to contaminated blood and body fluids of patients. Occupational exposure to blood and body fluids among healthcare workers is on the rise in Ghana. However, the relationship between self-reported exposures to blood and body fluids suspected to be contaminated with the hepatitis B virus and actual serological evidence of exposure remains unknown. The aim of the study however was to assess the self-reported exposure to HBV as against the serological evidence of lifetime exposure to HBV and associated factors among Ghanaian HCWs.

Methods

The study was a cross-sectional analytical survey that involved 340 HCWs who were recruited using a simple random sampling procedure from six cadres of staff from five districts in Greater Accra. The participants were surveyed using a validated instrument and 5mls of venous blood was aseptically withdrawn for qualitative detection of Anti-HBc. SPSS version 23.0 was used to analyze the data to obtain proportions, odds ratios and their corresponding confidence intervals with the level of significance set at 0.05.

Results

The response rate was 94% with Nurses and Doctors in the majority with a mean age of 35.6 ± 7.2. Self-reported exposure to HBV was 63% whereas lifetime exposure to HBV (Anti-HBc) prevalence was 8.2% (95% CI = 5.0-11.0%). Females were 60% less likely to be exposed to HBV (aOR = 0.4; 95% CI = 0.1–0.9) than their male counterparts. HCWs without training in the prevention of blood-borne infections had almost three times higher odds of being exposed to HBV in their lifetime (aOR = 2.6; 95% CI = 1.0-6.4).

Conclusions

The findings of this study suggest that self-reported exposure to HBV-contaminated biological materials was high with a corresponding high lifetime exposure to HBV. The female gender was protective of anti-HBc acquisition. Apart from direct interventions for preventing occupational exposures to HBV in the healthcare setting, periodic training of all categories of healthcare workers in infection prevention techniques could significantly reduce exposure to the Hepatitis B virus.

Keywords

Health care worker
Hepatitis B virus infection
Lifetime exposure
Self-reported
Serological evidence
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground to the study

Hepatitis B virus (HBV) infection is a major public health problem which is associated with severe complications namely, liver cancer and cirrhosis [1]. According to experts, HBV infection is ranked among the top health challenges of the world and was declared the tenth leading cause of mortality (786,000 deaths per year) [2]. These data necessitated its inclusion in the major global health priorities requiring urgent global action [1]. Healthcare workers are at risk of HBV as studies have reported a higher risk of infection in this population compared to the general population [3]. Reports available indicate that the risk of HBV infection among HCWs in Sub-Saharan Africa and Ghana specifically is greater due to the high prevalence of the disease in the general population [4].

In the healthcare setting, transmission of HBV may occur via several routes, but the most frequent route leading to the establishment of HBV infection is needlestick injury or sharp injury, collectively called percutaneous exposures [5]. The occurrence of this exposure form is high especially in Africa as a recent meta-analysis of studies done among HCWs revealed a pooled prevalence of 36% [6]. In Ghana, specifically, researchers have reported a higher prevalence of percutaneous exposures among HCWs. For example, In the middle belt of Ghana, Obirikorang et al., (2018), Appiagyei et al., (2021) and Lori et al., (2016) reported percutaneous exposure rates of 47%, 29% and 30% respectively [7–9] and in the Northern sector of Ghana, an exposure prevalence as high as 87.2% was reported [10]. In the Greater Accra region which represents the southern zone of the country, an exposure prevalence of 53.4% was recently reported among HCWs [11]. All these figures are indicative of the increasing risk of HBV infection among Ghanaian HCWs. Surprisingly, in the face of this high exposure rate to HBV and other bloodborne pathogens, HBV vaccination coverage, Post post-exposure prophylaxis (PEP) uptake and the practice of standard precautions which are all life-saving HBV prevention interventions are sub-optimal in this population [12–18]. Perhaps this is one factor that has contributed to the reported high prevalence of HBV among HCWs in Ghana [19].

Given the high rate of percutaneous exposures among Ghanaian HCWs, we contend that a lot more Ghanaian healthcare workers who suffer from these exposures have encountered HBV which can eventually translate to actual HBV infections given the sub-optimal HBV preventive behaviour among this population. We, therefore, sought to assess the self-reported percutaneous exposure to biological products suspected to be contaminated with HBV vis avi the serological evidence of exposure to HBV (Anti-HBc) among HCWs who performed direct patient care activities in selected health facilities in Southern Ghana.

Study methods

Design

The study was a cross-sectional study conducted in the Greater Accra Region of Ghana. The study assessed self-reported exposure to biological materials suspected to be contaminated with HB (in the past 12 months) and lifetime exposure to HBV (Anti-HBs) among healthcare workers who were recruited from five health institutions in the Greater Accra Region.

Study setting

The study was conducted in the Greater Accra Region which is the capital of Ghana. The Region has the highest number of health facilities and healthcare workers. Health services in the region are provided by a network of health facilities comprising 707 Community-Based Health Planning Services (CHPS) facilities, 299 clinics, 101 maternity homes, 32 health centres, 22 polyclinics, and 111 hospitals. In addition, there is one Regional Hospital, one Teaching Hospital and one University Hospital as well as two psychiatry hospitals located within the region. The health facilities in the region are owned by the government, the Christian Health Association of Ghana (CHAG), private individuals and organizations and some are also quasi-governmental in terms of ownership. The health facilities in the capital city appear to be better equipped than those in the other parts of the country and the HCWs working in these facilities are exposed to blood and body fluids due to their constant care and interaction with clients. Studies have reported a high rate of exposure to blood and body fluids of 53.4% [11] and a high HBV prevalence of 5.9% [19] among HCWs working in the region.

Study population

Participants of this study belong to professional groups namely Doctors, Nurses, Laboratory staff, Anesthetists, Physician Assistants and Sanitation workers (Orderlies). These categories of HCWs were recruited from 5 health facilities which were selected randomly from the list of facilities in the Region. The participants were those who volunteered to answer the questions in the research instrument and also consented for their blood samples to be taken and analyzed for lifetime exposure to HBV, otherwise referred to as the presence of Anti-HBc. The inclusion criteria include being a permanent employee of the facility, belonging to a professional category with direct involvement in patient care and being at the post for the past 12 months. Students and those on internships were excluded from the study.

Sample size estimation

Researchers elsewhere established that the HBV infection rate can be four times higher in HCWs compared to the general population [20]. Given that the prevalence of HBV in the general Ghanaian population has been estimated at 12.3% [21], we anticipated an Anti-HBc prevalence of 50% which is four times the 12.3% estimated for the general Ghanaian population (12.3*4 = 50%). We used the 50% as anticipated prevalence (p) to estimate the sample size. With a margin of error of 5% and, a z-value of 1.96, a minimum sample size of 340 was deemed adequate for the study.

Sampling procedure

Allocation of HCWs to the selected study sites was done proportionate to size (staff strength) in each selected facility, HCWs were again stratified into six cadres of staff (Doctors, Nurses/Midwives, Laboratory Staff, Physician Assistants, Anesthetists, and orderlies) proportionate to size. The category-specific staff list for each of the study sites served as a sampling frame for the simple random sampling procedure. The lottery method, which is a probability sampling technique was employed to randomly select eligible participants for the study.

Data collection instrument

The data collection instrument utilized in this study was a structured questionnaire which was developed based on occupational exposure and HBV infection risk variables obtained from related literature. The questions ranged from socio-demographic characteristics such as age, sex, level of education etc. The tool also had questions on occupational exposures (percutaneous and mucocutaneous exposures). The third section of the instrument had questions on behavioural factors that have the potential to increase the risk of encounters with HBV. These include lifetime surgery, dental procedures etc. The tool was subjected to expert review as well as pretesting which was done in a Health Center in the study Region, and the pretesting procedure involved 20 participants. The questionnaire was revised per the comments and suggestions of the experts and the outcome of the pretesting procedure. The scale utilized for the assessment of risk perception for HBV had a Cronbach’s alpha (α) of > 7 when subjected to reliability testing.

Data collection and laboratory procedure

The research instrument was self-administered to all consenting HCWs in this case participants indicated their responses by answering the questions directly on the questionnaires. As indicated in an already published related study [22] 5 ml of venous blood was aseptically collected under a strict WHO-recommended phlebotomy procedure. The blood sample was centrifuged and transported under cold chain conditions to a central laboratory. Qualitative detection of the serological marker denoting lifetime exposure to HBV (HBcAb or Anti-HBc) was done using a Hepatitis B Virus Profile Kit called Advanced Quality TM One Step multi-HBV Test Device Cassette (In Tec Products, Inc.). The recommended volume of serum samples was dropped into the wells designated on the test device. The results were read in 15 min. Identification of Anti-HBc from test results was done as recommended by the manufacturer.

Data analysis

Study variables

One independent variable in this study which represents a risk of exposure to HBV other than an occupational hazard is ‘behavioural risk’. These factors included blood transfusion, intimate contact with a known HBV carrier, dental procedure, lifetime surgery tattoo or scarification etc. Individuals with none of the behavioural risk factors were classified as having no risk, those with 1–3 factors as intermediate risk and those with 4 or more risk factors as being at high risk of exposure and infection with HBV [23].

Facility factor was another important independent variable which was assessed in this study. HCWs from health facilities with HBV logistics, HBV prevention systems, protocols and programs are considered to have good facility factors. Health facilities below the secondary level were classified as being in the lower facility category whereas those at and above the secondary level were classified as higher-level facilities.

Data analysis procedure

Data entry and analysis were done using SPSS version 23 software. Data was presented in tables. Analysis of categorical variables was presented in proportions. Pearson’s chi-square test and Fisher’s exact tests were performed to assess associations between Lifetime exposure (Anti-HBs) and the personal and occupational characteristics of study participants. Variables that showed statistical significance at the bivariate level were marked for the next stage where simple logistic regression was performed to estimate the strength of the association between lifetime exposure and the independent variables. Using the rule of thumb, all the variables whose p-value < 0.25 were included in the model for multivariable logistic regression analysis [24] which was subsequently undertaken to adjust for behavioural and personal factors that could influence Anti-HBs acquisition. Some important clinical variables were included in the model irrespective of their statistical performance [24]. The first category under each categorical variable by default was used as a reference group in the logistic analysis procedure. The logistic regression assumptions of no multicollinearity and independent observations were respected. Hosmer-Lemeshow goodness of fit test was used to measure or evaluate model fit.

Ethical considerations

The Institutional Review Board of the Noguchi Memorial Institute of Medical Research approved the study protocol (005/17–18). Permission was obtained from both the regional and the district/municipal health directorates within which the five health facilities were located. Heads of the five health institutions were duly informed. The nature, purpose and procedures associated with the study were communicated to all participants after which they filled a consent form as a way of demonstrating their willingness to participate in the study. Confidentiality was ensured regarding test results. The principal investigator was the only one responsible for communicating the test results to the participants. Those who tested positive for Anti-HBc were counselled and given referral letters to be adequately evaluated for other serological tests (HBsAg) to ascertain their HBV infection status. All source documents were de-identified by use of serial numbers to ensure anonymity.

Results

Sociodemographic profile of the healthcare workers

The majority of the participants were females, (n = 252; 74.1%) who were aged 34.5 (SD ± 7.7). Close to 70% of the participants worked in secondary-level health facilities with corresponding high Outpatient attendance and varying degrees of exposure-prone procedures. The majority of the HCWs (n = 299; 88.0%) were educated up to tertiary level and beyond. Doctors, Nurses/ and midwives dominated the sample (n = 231; 68%). Most of the participants (n = 260;76.5%) had less than 10 years of professional experience. Close to half (n = 155; 45.6%) worked in hospital departments or work areas considered high-risk areas where blood-borne pathogen exposure risk is high. Three-fourths of the participants (n = 274; 80.6%) had attended training in the prevention of hospital-acquired infection in the last 12 months. The majority of the HCWs who participated in the study (n = 237;70%) work in health facilities with an abundance of the needed logistics, programs and systems to protect HCWs from HBV hence they were considered as working in supportive health facilities. Behavioural exposure to HBV risk was assessed to be high in the minority of the study participants (44;12.9%). The majority of the HCWs (295; 86.6%) perceive HBV to be highly infectious, with serious health consequences.

Self-reported exposure to blood and body fluids suspected to be contaminated with HBV

As presented in Fig. 1, the majority of the study participants (63%) admitted ever being exposed to blood and body fluid they suspect to have been contaminated with HBV. These exposures were mainly through percutaneous exposures (n = 112; 33%) and other mechanisms. Body fluid that was predominantly mentioned was blood (n = 200;58.9%) (Table 1).

Fig. 1 Self-reported blood and body fluid exposure status among participants

Table 1 Sociodemographic profile of participants

Variables	N(340)	Percent (100%)	
Age of Category of Participants			
Less than 30 years	127	37.4	
Age 30 Years or More	213	62.6	
Sex of study participants			
Male HCWs	88	25.9	
Female HCWs	252	74.1	
Level of education			
Tertiary and above.	41	12.0	
Below Tertiary	299	88.0	
Professional Group			
Doctors, Nurses & Midwives	231	68.0	
Other Categories	109	32.0	
HBV acquisition Risk criteria			
No risk of HBV acquisition	44	12.9	
Medium to moderate risk	269	79.1	
High risk of acquisition	27	8.0	
Perception of susceptibility, severity of HBV*			
Good risk perception	295	86.8	
Poor risk perception	45	13.2	
Length of professional experience			
Less than 10 years	260	76.5	
10 years and above	80	23.5	
Level of Healthcare Delivery			
Secondary and Tertiary	237	69.7	
Primary level	103	30.3	
Health Facility support indicator			
Very supportive	237	69.7	
Less supportive	103	30.3	
Work Department**			
Critical or high-risk unit	155	45.6	
Non-critical or medium to low-risk unit	185	54.4	
Training in blood-borne infection prevention			
Trained in infection prevention	274	80.6	
Not Trained in infection prevention	66	19.4	
Type of exposure			
Other forms	104	30.6	
Percutaneous	112	32.9	
None	124	36.4	
Type of biological material exposed to			
Blood	200	58.8	
Other body fluids	16	4.7	
No Exposure	124	36.5	
* Perception of susceptibility and severity refers to having the perception that HBV is a serious disease, one is at risk of the disease and the benefits of preventing outweigh the cost

** Work unit refers to the department of work with critical units having a higher risk of blood and body fluid exposure

Serological evidence of Anti-HBc positivity among HCWs

In all, 28 participants had serological evidence of HBV exposure giving an Anti-HBc positivity rate of 8.2%, 95% CI (5-11%). Results presented in Table 2 show that HCWs who were below 30 years of age had a higher frequency of exposure giving a proportion of 9.4%. The frequency of lifetime exposure to HBV was higher (15.2%) in HCWs who received no training in infection prevention and control compared to their trained counterparts and this observation was significant at the bivariate level (p = 0.023).

Table 2 Serological evidence of Anti-HBc positivity in healthcare workers

Variables	N(340)	(Anti-HBc positivity)	
n(28)	Percent (95% CI)	Chi	P-value	
Age category of HCWs				0.40	0.530	
Less or equal to 30 years	127	12	9.4(5-15.9)			
Age 30 years or more	213	16	7.5(4.4–11.9)			
Sex of Study Participants				4.58	0.032	
Male HCWs	88	12	13.6(7.2–22.6)			
Female HCWs	252	16	6.3(3.7–10.1)			
Level of Education				***	0.760	
Tertiary and above.	41	24	9.8(2.7–23.1)			
Below Tertiary	299	4	8.0(5.2–11.7)			
Professional Group				1.60	0.201	
Doctors/Nurses	231	16	6.9(4–11)			
Others	109	12	11.0(5.8–18.4)			
HBV acquisition risk criteria				2.00	0.377	
No risk of HBV acquisition	44	6	13.6(5.2–27.4)			
Medium to moderate risk of HBV acquisition	269	20	7.4(4.6–11.2)			
High risk of HBV acquisition	27	2	7.4(9.1–24.3)			
Perception of susceptibility, severity of HBV				1.78	0.182	
Good risk perception	295	6	7.5(4.7–11.1)			
Poor risk perception	45	22	13.3(5.1–26.8)			
Length of professional experience				0.54	0.460	
Less than10 years	260	23	8.8(5.7–13)			
10 years and above	80	5	6.3(2.1–14)			
Level of healthcare delivery				3.76	0.052	
Secondary and Tertiary level	237	15	6.3(3.6–10.2)			
Primary level	103	13	12.6(6.9–20.6)			
Health facility support indicator				3.76	0.052	
Very supportive	237	15	6.3(3.6–10.2)			
Less supportive	103	13	12.6(6.9–20.6)			
Work Department				1.64	0.200	
Critical or high-risk unit	155	16	10.3(6-16.2)			
Non-critical or medium to low-risk unit	185	12	6.5(3.4–11.1)			
Training in IPC €				5.18	0.023	
Trained	274	18	6.6(3.9–10.2)			
Not Trained	66	10	15.2(7.5–26.1)			
Self-reported exposure				0.82	0.365	
Exposure	216	20	9.3(5.7–13.9)			
No exposure	124	8	6.5(2.8–12.3)			
Type of exposure				0.68	0.410	
Other forms	104	20	19.2(14.7–21.5)			
Percutaneous	112	5	4.5(4.7–19.7)			
None	124	3	2.4 (3.1–7.8)			
Type of biological material exposed to				0.44	0.231	
Blood	200	18	9.0(7.4–14.1)			
Other body fluids	16	7	43.7(37.1–48.4)			
None	124	3	2.4 (3.1–7.8)			
* Risk perception refers to having the perception that HBV is a serious disease, one is at risk of the disease and the benefits of preventing outweigh the cost

** Work department refers to the department of work with critical units having a higher risk of blood and body fluid exposure

*** Estimates from Fishers’ Exact Test. NSIs¥= Needle stick injury, €Infection prevention and control

The study also observed higher rates of HBV exposure among male HCWs (13.6%) than their female counterparts and this relationship was also significant (p = 0.032) at the bivariate level. Participants belonging to categories other than the nurse/doctor category had a higher prevalence of 11.0%.

A higher Anti-HBs prevalence was observed among HCWs working in lower-level settings, 13 (12.6%), and those working in critical units were much more exposed to blood and body fluid (10.3%). Again, a higher exposure rate was observed among individuals working in settings where facility levels systems and structures for HBV prevention were observed to be poor 13 (12.6%) and HCWs who had worked for less than 10 years (8.8%) in their various professions (Table 2).

After controlling for behavioural and occupational factors, the results presented in Table 3. show that not receiving training in the prevention of blood-borne infections increased the odds of lifetime exposure to HBV (aOR = 2.6; 95% CI = 1.0-6.4). Also, the female gender was protective of Anti-HBc and therefore reduced the odds of lifetime exposure (aOR = 0.4; 95%CI = 0.1–0.9). (Table 3).

Table 3 Factors associated with Anti-HBc acquisition among HCWs (Data has previously be published in [19])

Variables	N(340)	Anti-HBc	Crude Estimates		Adjusted Estimates		
n(28)	uOR (95% CI)	P-value	aOR (95% CI)	P-value	
Age category of HCWs				0.530		0.836	
Less than 30 years	127	12	1.0		1.0		
Age 30 years or more	213	16	0.8(0.4–1.7)		0.9(0.4–2.3)		
Sex of study participants				0.036		0.026	
Male HCWs	88	12	1.0		1.0		
Female HCWs	252	16	0.4(0.2–0.9)		0.4(0.1–0.9)		
Level of Education				0.706		0.185	
Tertiary and above.	41	24	1.0		1.0		
Below tertiary	299	4	0.8(0.3–2.5)		0.4(0.1–1.5)		
Professional Group				0.205		0.661	
Doctors/Nurses	231	16	1.0		1.0		
Other categories	109	12	0.6(0.3–1.3)		0.8(0.3–2.1)		
HBV acquisition Risk criteria							
No risk of HBV acquisition	44	6	1.0		1.0		
Medium to moderate risk	269	20	0.5(0.2–1.3)	0.174	0.5(0.2–1.6)	0.280	
High risk of acquisition	27	2	0.5(0.1–2.7)	0.427	0.6(0.1–3.8)	0.584	
Perception of susceptibility of HBV				0.367		0.202	
Good risk perception	295	6	1.0		1.0		
Poor risk perception	45	22	0.7(0.3–1.6)		2.1(0.7–6.3)		
Length of Professional experience				0.462		0.773	
Less than 10 years	260	23	1.0		1.0		
10 years and above	80	5	1.5(0.5–4)		1.2(0.4–3.7)		
Level of healthcare delivery				0.005		0.704	
Secondary and tertiary level	237	15	1.0		1.0		
Primary Level	103	13	2.1(1.1–4.7)		2.0(0.1–65)		
Health facility Support Indicator				0.057		0.741	
Very supportive	237	15	1.0		1.0		
Less supportive	103	13	2.1(1–4.7)		1.8(0.1–58.7)		
Work Department				0.204		0.120	
Critical or high-risk unit	155	16	1.0		1.0		
Non-Critical or medium to low-risk unit	185	12	0.6(0.3–1.3)		0.5(0.2–1.2)		
Training in blood borne IPC €				0.027		0.044	
Trained in infection prevention	274	18	1.0		1.0		
Not Trained in infection prevention	66	10	2.5(1.1–5.8)		2.6(1.1–6.4)		
Self-reported exposure				0.241		0.191	
Exposure	216	20	1.0		1.0		
No exposure	124	8	0.6(0.3–1.4)		0.5(0.2–1.4)		
* Risk perception refers to having the perception that HBV is a serious disease, one is at risk of the disease and the benefits of preventing outweigh the cost

** Work department refers to the department of work with critical units having a higher risk of blood and body fluid exposure, €Infection prevention and control

Discussion

This present study sought to estimate the prevalence of self-reported exposure to HBV and the prevalence of Anti-HBc antibodies denoting lifetime exposure to hepatitis B virus. These two indicators are related in that one is from the HCW perspective or experiences of exposures to blood and body fluids suspected to be contaminated with HBV and the other is serological evidence of having a lifetime encounter with HBV.

In this study, self-reported exposure to biological materials or products suspected to be contaminated with HBV was as high as 63% which is higher than the global prevalence of 44.5% reported in a systematic review [25]. The finding of this study is also higher than the 53.4% reported among HCWs who were surveyed in the same region [11] but lower than the 87.2% reported by Alaru et al., (2023) from the Northern belt of Ghana [10]. The Northern belt of Ghana is less developed compared to the southern sector where this present study was done. There is evidence to show that, healthcare settings in resource-endowed regions have policies that are directed at protecting HCWs from occupational exposures compared to resource-poor settings [26]. Occupational health experts believe that HCWs’ safety behaviours appear to be optimal in urban and highly developed settings compared to rural settings [4]. This may probably be the reason for the remarkable difference in the exposure prevalence in the study region and the northern belt of Ghana. The same reason explains the findings from a global-level systematic review which reported a higher prevalence of occupational exposures among HCWs in less developed countries compared to those in the Americas [25]. The high exposure prevalence observed in this study has implications for HCW safety as these exposures could translate into actual HBV infections in the face of sub-optimal pre and post-exposure prophylaxis uptake among the Ghanaian HCWs [27]. Health facility level, as well as health system policy directives and guidelines, are urgently needed to drive facility-level interventions targeted at reducing these occupational exposures.

Anti-HBc denoting lifetime exposure to HBV was isolated in 8. 2%. of the study population. The difference in the two indicators being reported (8.2% for Anti-HBc and 63% for self-reported occupational exposure) in this study is not surprising. The authors of this study have the understanding that not all exposures sustained by HCWs, be it mucocutaneous, percutaneous or non-intact skin would lead to the transmission of HBV. This is because studies have demonstrated that the transmission and for that matter the acquisition of HBV by non-infected, non-immune HCW is dependent on the HBeAg status and viral load of the source patient, the type of body fluid involved, the degree or extent of the exposure and also the type of medical procedure involved [3]. This notwithstanding, it is not all individuals who have the biological advantage to fight the HBV upon having an occupational exposure. This is because studies have demonstrated that 37% of HBV infections among HCWs are a result of occupational exposures [28]. This provides the basis for the recommendation for HCWs to obtain maximum protection against HBV by taking advantage of the high efficacy rate of the HBV vaccine [29, 30] and protecting themselves from the infection and its life-threatening complications.

The Anti-HBc prevalence estimated in our study is lower than 60.1% and 48.1% reported in a related study among Ugandan HCWs [31, 32]. On the contrary, the findings of our study are two times higher than estimates from a related research which reported an Anti-HBc prevalence of 4.1% among HCWs in an European country [33]. HBV exposure and corresponding infection are known to be prevalent among HCWs in low-income countries, particularly in Africa compared to Western and well-developed countries where the disease is less endemic [4]. The differences in the results of the two studies mirror the geographical dispersal of HBV infection and the level of endemicity. This is because anti-HBc prevalence has a direct and positive correlation with HBsAg prevalence in most populations [34].

Again, the lifetime exposure to HBV that as reported in this study is slightly higher than the prevalence of actual HBV infections (HBsAg positivity) of 5.9% reported recently among the same population of Ghanaian HCWs (the two studies were done simultaneously) among the same participants [19]. There is the possibility that some of the HCWs who were exposed to HBV were able to fight the virus, and perhaps developed active immunity against the virus. This could probably explain the difference in the prevalence of lifetime exposure and the prevalence of current HBV infection (HBsAg positivity) reported in the related study. Comparing these two studies, it is clear that just about 2% of exposed HCWs had resolved infections indicating that reliance on naturally acquired immunity against HBV may not be the best strategy for HBV prevention in this population. This explanation gives credence to the fact that vaccination against HBV is the mainstay for HBV prevention especially among HCWs who constantly suffer exposures to blood and body fluids since vaccination offers a better and higher level of seroprotection against HBV.

This study found that the female gender was protective for Anti-HBc acquisition as female HCWs in this study demonstrated lesser odds of having serological evidence of exposure to HBV. This observation is not new because studies done in America, Brazil and Nigeria have equally reported a lower risk of exposure and HBV antigenemia among female HCWs compared to their male counterparts [35–37]. This is probably due to a higher level of adherence to HBV preventive measures among female HCWs compared to their male counterparts [38–40]. This observation implies that the burden of HBV exposure and subsequent infection may be higher in male HCWs than their female counterparts and hence the need to target this gender category much more in HBV preventive programs with so much attention paid to their adherence to standard precautions and uptake of pre- and post-exposure prophylaxis.

The study also found that receipt of training in infection prevention significantly reduced the odds of having serological evidence of HBV exposure. Similarly, an African study recently reported that the risk of occupational exposure to HBV was significantly higher in HCWs who lack training in infection prevention and control compared to those who received optimum training [6]. Healthcare worker training and educational programs ensure optimum human resources knowledge, skills development and performance through planned and coordinated training and educational programmes. Specifically, In-service training for HCWs in the area of HBV prevention is crucial specifically for sustaining HBV preventive behaviour and maintaining HCW competencies in general. Researchers from Egypt and the United States suggest that in-service training in blood-borne infection prevention in health facilities has the potential to increase the overall safety of HCW through increasing knowledge and promotion of positive attitudes towards the prevention of HBV and other blood-borne infections [41, 42].

We infer from this study that continuous training for HCWs can significantly reduce HCWs’ risk of exposure to HBV and therefore recommend repeated onsite in-service training for all categories of HCWs especially in resource-poor settings. We therefore call for continuous evaluation of the impact of these training sessions on the HCW populations. We strongly advocate for the training programmes to be appropriately designed using holistic approaches that will trigger behavioural change and ultimately improve HBV preventive behaviour.

Study limitations

This study employed a cross-sectional design, implying that the observed association may not necessarily imply a causal relationship. Moreover, recall bias and social desirability bias could affect the accuracy of the data that was collected from the participants on reported biological material exposures. Again, data was collected from HCWs working in only public or government-owned facilities in the Greater Accra Region. This represents sampling bias since HCWs working in other regions and private health facilities may have different levels of HBV exposure.

Conclusions

The findings of this study suggest that self-reported exposure to HBV-contaminated biological materials was high with a corresponding high lifetime exposure to hepatitis B virus. The female gender was protective of Anti-HBc acquisition. Periodic training for healthcare workers on bloodborne infection prevention has the potential to prevent the occurrence of blood and body fluid exposures in the healthcare setting and this can translate into a significant reduction in the risk of occupational exposure to the hepatitis B virus.

Acknowledgements

We thank all the respondents who participated voluntarily in the study and a special thanks to the research assistants who made this project possible.

Author contributions

Senoo-Dogbey V.E. Conceptualization, Methodology, Software, Data curation, Writing, Original draft, Preparation, Visualization, Investigation, Validation. Klutse: E.E. Methodology, Investigation, Validation, Writing, Original draft, Preparation Reviewing and Editing,

Funding

This research received no funds or grants from public, private, or nonprofit agencies.

Data availability

Data is available from the corresponding authour upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from the local ethical review committee in Ghana. Facility heads and hospital administrators granted permission for data collection to be undertaken.

Informed consent to participate

The participants were informed about the study’s objectives and valid written consent was obtained before the data collection could begin. The respondents had the right to refuse, withdraw, or terminate at any point without giving any reason. The information provided by the respondents was treated with the highest degree of confidentiality.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

Anti–HBc Hepatitis B Core Antibody

CDC Centre for Disease Control

CHPS Community-based Health Planning and Services

GHS Ghana Health Service

HBV Hepatitis B virus

HBsAg Hepatitis B Surface Antigen

HCWs Healthcare workers

WHO World Health Organisation

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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