Assessment of risk profile of medical and dental students regarding hospital-associated infections in Nigeria
193 total views, 1 views today
Background: Medical education involves intense clinical training which necessitates exposure of the medical and dental students to patients. In some instances, the student comes in contact with infectious diseases and are vulnerable to getting infected or by themselves becoming a carrier of the disease.
Objectives: We aim to assess the risk profile of medical and dental students in clinical settings in terms of hospital-associated infections.
Study Design: This is a cross sectional studies conducted among medical and dental students in Nigeria, with focus on 4th to 6th year students from 4 Public universities using anonymous structured questionnaire.
Result: Two hundred and ninety-five (295) participants were enrolled in this study. The mean (±SD) age of the respondents was 23.45 (±2.88) years. The majority (65.1%) of them were males, 82.4% were medical students. Only 68% of the respondents reported that they had received a comprehensive lecture on infection control in the course of their training. Less than half of the respondents indicated that their institutions provide free vaccination against tetanus, hepatitis, yellow fever, and cerebrospinal meningitis. 47.1% and 57.3% of the respondents keep their clinical apparels in their school bag and room wardrobe, respectively. More than 70% of the respondents agreed that hand washing is the most important step in infection control. However, only a minority (<40%) always practice hand washing in accordance with recommendation.
Conclusion: The present study shows that there is a need for improvement in the attitude and practice of medical students towards hand hygiene use and vaccination. There is also a need for advocacy in institutionalization of preventive measures for the control of nosocomial infections.
Keywords: Medical students, Infection control, vaccination
Pathogenic microscopic agents, ranging from prions to viruses and bacteria, pose significant and continual threats to human existence.1–4 They are responsible for diverse infectious diseases, some of which manifest only with mild symptoms while some could result in a severe life-threatening process.1–4 Scientific research has over the years shaped human approach toward infection prevention and control.5–8 Through scientific discoveries about the nature, structure, and functions of pathogenic microscopic agents, our way of life, as human beings, had been modified in a positive direction.9,10 For instance, human knowledge of the health risks (e.g. cholera infection) posed by open defecation has made human beings to develop and adopt use of safe toilets for faecal disposal.11 Similarly, the knowledge of faeco-oral route of transmission of some pathogenic microscopic agents have made man to develop and adopt the habit of frequent hand washing practices.2 In summary, medical science has shaped our lifestyles and habits when it comes to issues pertaining to the prevention and control of infection.
There are so many personal and communal benefits associated with effective and safe infection control practices, be it hand hygiene, food hygiene, garment hygiene, environmental sanitation, or any other.12 These benefits range from health benefits to socioeconomic benefits, and they include: protection against diseases and epidemic outbreaks; lowered health system costs; increased work productivity; healthy, strong and vibrant national workforce; and others.12,13
However, despite the significant benefits associated with the practice of infection control, so many people are still at very high risk of contracting infectious diseases due to their unsafe behavioural practices.4,11 Pertinently, scientific research have shown that so many people, including healthcare professionals and trainees, are not practicing some basic infection control practices (including hand and food hygiene) effectively.14–23 The reasons implicated for these poor infection control practices were poor knowledge/lack of proper training on infection control practices,15–20,24 poor attitude towards hygienic practices,18 low level of formal education,18 inadequate access to water and other resources needed for hygienic practices,17 and others.
In a developing African country like Nigeria, recent epidemiological surveys had shown that the level of infection control among healthcare professionals is still unsatisfactory.20,25,26 With this concerning situation, it will be very difficult to completely nib the risk of nosocomial infections among patients and personnel in Nigerian hospitals in the bud.27,28 Despite several studies that have been conducted on infection control practices in Nigerian healthcare settings, no particular study had deeply explored this thematic area among medical and dental students (a subset of the population of healthcare trainees in Nigeria).20,22,25 In order to fill this knowledge gap, this study was conducted to assess the risk profile of medical and dental students in Nigeria regarding hospital-associated infections.
This study was a descriptive cross-sectional study conducted among medical and dental students in Nigeria, with focus on 4th to 6th year students. We focused this study only on the 4th to 6th year students because they are all in the clinical phase of their academic programs, and they are expected to have some knowledge about the pathogenesis of infectious diseases.29 This study only surveyed 4 Public universities, which were: University of Ibadan, Ibadan (UI); Obafemi Awolowo University, Ile-Ife (OAU); Ladoke Akintola University of Technology, Ogbomosho (LAUTECH); and Usmanu Dan Fodiyo University, Sokoto (UDU).
The study tool was a piloted anonymous structured questionnaire developed by the authors. The questionnaire obtained information about the participants’ socio-demographic characteristics, history of receipt of a comprehensive lecture on infection control, knowledge of infectious diseases, knowledge and practice on hand washing, access and use of personal protective equipment (PPE), access to institution-based immunization programme, and immunization profile. Calculated minimum sample size for the study was 290 participants. All the 4 participating schools were selected based on accessibility to the authors.
Between March 2016 and January 2018, a total of 361 (UI = 125, LAUTECH = 56, OAU = 100, and UDU = 80) selected clinical medical and dental students were approached in their dormitories and classrooms. They were informed about the aims and objectives of the study; they were also assured that their participation was strictly confidential and voluntary, and that they were free to opt out of the study at will. Data was computed and analysed using SPSS version 20 software. Data were presented in frequencies, proportions, means and standard deviations. Continuous variables were summarized in means and standard deviations while categorical variables were summarized in frequencies and proportions and presented in tables and charts. Statistical analysis of continuous variables was done using Student’s T tests while categorical variables were analysed using Chi-square test (with Yate’s correction in cases where greater than 20% of expected count is less than 5). Analysed data were presented in words, charts, and tables.
Figure 1: Respondents’ history of receipt of a comprehensive lecture on infection control
Out of the 361 students that were approached, only 307 (UI = 118, LAUTECH = 34, OAU = 82, and UDU = 73) agreed to participate in the study by giving a verbal informed consent. All the 307 consenting students (i.e. participants) were issued questionnaires to fill and returned. Only 302 (UI = 118, LAUTECH = 32, OAU = 80, and UDU = 72) participants returned their questionnaires. Hence, 7 questionnaires (UI = 1, LAUTECH = 2, OAU = 1, and UDU = 3), out of the returned 302 questionnaires, were discarded at data cleaning stage because they were unfilled/have a completeness rate of <80%. Finally, only the data from 295 (UI = 117, LAUTECH = 30, OAU = 79, and UDU = 69) participants were analysed with some questionnaires having missing data which ranged from 0.3% (academic level) to 16.6% (immunization history). Since missing data level was <20% overall, a complete case analysis was done for each variable.
Socio-demographic Characteristics of Respondents
The mean (±SD) age of the respondents was 23.45 (±2.88) years. The majority (65.1%) of them were males, 82.4% were medical students, 45.4% were in 400 level (4th year), 67.4% were residing in the university hostel, 61.7% were living on-campus, and 60.0% have 1 to 3 co-occupants in their room (Table 1).
Knowledge of Respondents on Infection Control
Only 68% of the respondents reported that they had received a comprehensive lecture on infection control in the course of their training (Figure 1), meanwhile, according to the Nigerian medical and dental educational curriculum29, the surveyed respondents are expected to have received at least one lecture on infection control practices.
Bivariate analysis shows that a higher proportion of those respondents with history of receipt of a comprehensive lecture on infection control knew about the infectious diseases they were asked about, when compared with those without such history (Table 2).
The majority (>70%) of the respondents agreed that hand washing is the most important step in infection control. Also, the majority (>70%) of them believed that it is important to wash the hand: before and after touching a patient; before doing a clean/aseptic procedure; after exposure to body fluid; and after touching patient-exposed surfaces. However, only a minority (<40%) always practice hand washing in accordance with timing (i.e. before and/or after a hand contact). Furthermore, as per the important surfaces of the hand to wash, over 60% agreed that the palm, back of the hand, thumb, inter-digital surfaces, fingernails, and the wrists are important surfaces to wash (Table 3).
Access to Hand Hygiene Resources among Respondents
In terms of availability to hand hygiene resources, only 85.1%, 55.9%, and 33.6% of the respondents usually have access to running water, liquid soap, and electric hand dryer, respectively. Meanwhile, less than 35% had all-time clinical access to, and use of, hand sterilant, hand gloves, and face masks (Tables 3 & 4).
Handling, Care and Use of Clinical Apparels among Respondents
The clinical apparels (ward coats, theatre linens, lab coat) of the majority (96.6%) of the respondents were personally sourced (i.e. they were not provided by their institution); of which as few as 9.5% of them (i.e. those with personally sourced clinical apparels) always wash their clinical apparels with disinfectant solution. It is noteworthy that as high as 47.1% and 57.3% of the respondents keep their clinical apparels in their school bag and room wardrobe, respectively. Also, 44.4% had never sourced for clinical apparel to wear through borrowing while 46.1% sometimes wear their clinical apparel to the cafeteria (Table 5).
Immunization Access and History among Respondents
Regarding the provision of free and relevant immunization services by the institution of learning, less than half of the respondents indicated that their institutions provide free vaccination against tetanus, hepatitis, yellow fever, and cerebrospinal meningitis (Table 6). Finally, many of the respondents reported that they have not being vaccinated against some common infectious diseases of importance in clinical practice and public health (Table 7).
This survey revealed that a large percentage of clinical medical/dental students are yet to receive a comprehensive lecture on infection control and prevention. It is advocated that healthcare associated infections are preventable by following Infection Control protocols which are not often taught to medical student. Poor state of knowledge and practices in medical students about infection control has been shown in various studies.30–36 The WHO strongly recommends incorporation of Patient Safety Module into the curriculum of medical schools as, the future doctors need to understand these concepts at an early stage to be able to incorporate them into their practice. This module includes a topic on minimizing infection through improved infection control which should focus on standard precautions including hand hygiene, sterilisation and disinfection, spillage, biomedical waste management, sharp injuries, use of personal protective equipment and vaccination.37 Combinations of teaching methods should be used to ensure that students participate actively in the sessions, suggested methods include interactive/didactic lectures, video show, small group discussion sessions, simulation exercises and demonstration.38
The spread of infection in health-care settings today affects hundreds of millions of people worldwide. In a WHO sponsored prevalence survey study conducted in 55 hospitals of 14 countries representing four WHO regions (South-East Asia, Europe, the Eastern Mediterranean and the Western Pacific) it was found that, on average, 8.7% of hospital patients suffer health care-associated infections. At any time, over 1.4 million people worldwide suffer from infectious complications acquired while in hospital being treated for a medical condition.39 It must be emphasised to the students that handwashing is the single most important infection control intervention before and after patient contact. Every health-care worker is required to act responsibly and without fail to apply the techniques for handwashing at every patient encounter. Students need to be instructed on how to clean hands, the rationale for choice of clean hand practice, techniques for hand hygiene, how to protect hands from contaminants and how to promote adherence to hand hygiene guidelines.37
It is widely reported that there could be a disparity hand washing knowledge and behaviour,21,31,32,34,40,41 medical educators can have a major influence on the hygiene behaviours of their trainees, mainly because of the imitation of the behaviours of the medical educators.42 Medical students and junior doctors were reported to have been influenced by their seniors.33 It is therefore pertinent that the culture of handwashing is institutionalised to ensure that the right behaviour is copied.
The availability of hand washing facility has a direct effect on hand hygiene measures. Availability of the handwashing station is reportedly low in the participating institution. This is similar to the findings of Onyedibe et al (2020) who reported poor availability of hand hygiene facilities in a large tertiary hospital in Nigeria.43 Similarly, WHO stated that 1 in 4 health facility had no running water and 1 in 3 had no hand washing facility at point of care,44 this has led to a recommendation issued to all member states of the WHO on 1 April 2020 to provide universal access to public hand hygiene stations and make their use obligatory, and to improve access to and the practice of hand hygiene in health care facilities.45 Improved access to hand hygiene facility will encourage the use of same.43 The use of portable hand hygiene stations have been studied and found to be cost effective in the immediate deployment of hand hygiene facility in resource limited areas.46,47 In situation where water and soap is not feasible, other options for hand hygiene are alcohols, Chlorhexidine, Chloroxylenol, Hexachlorophene, Iodine and iodophors, Quaternary ammonium compounds and Triclosan.44
Clinical apparel is an important vector for transmission of nosocomial infections.48,49 Many of our participants wear their ward coats (clinical apparel) to cafeteria, banks, lecture theatre, and other public places; this is an unsafe practice that can facilitate the rate of spread of infectious diseases at the community level. Also, majority of them acquire and process their ward coats and scrubs (clinical apparel) personally with most of them returning the ward coats to their hostel rooms. However, the standard practice is the processing of such apparel by the sanitation unit/department of the teaching hospitals where medical and dental students are receiving their clinical training.50,51 Hence, we recommend that all Nigerian teaching hospitals should ensure that workable policies are formulated and implemented regarding safe and proper handling and processing of all clinical apparels used by all students undergoing training in such hospitals.
Another important finding in this study is the uptake of vaccination. Vaccination has been shown to be effective in protecting against a variety of diseases. The most commonly reported vaccination was against polio and tetanus while vaccination against HBV, HPV and influenza was quite low. This is similar to reports from previous studies from Nigeria,52 Cameroon,53 Iran,54 and Poland.55 It is important that clinical medical/dental students are routinely vaccinated against common viral diseases by the institution. The vaccination should be provided free of charge via the institutional health insurance system and should be a requirement before deployment for clinical postings.
The present study shows that there is a need for improvement in the attitude and practice of medical students towards hand hygiene use and vaccination. There is also a need for advocacy in institutionalization of preventive measures control of nosocomial infections.
- Binns C, Low WY, Kyung LM. The COVID-19 Pandemic: Public Health and Epidemiology. Asia-Pacific J Public Heal 2020; 32: 140–144.
- Imran M, Mahmood S. An overview of human prion diseases. Virol J 2011; 8: 1–9.
- Rodrigues ML, Nosanchuk JD. Fungal diseases as neglected pathogens: A wake-up call to public health officials. PLoS Neglected Trop Dis 2020; 14: 1–9.
- Tappero J, Tauxe R. Lessons Learned during Public Health Response to Cholera Epidemic in Haiti and the Dominican Republic – Vol. 17 No. 11 – November 2011 – Emerging Infectious Disease journal – CDC. Emerg Infect Dis 2011; 17: 2087–2093.
- Woolhouse M, Scott F, Hudson Z, Howey R, Chase-Topping, M. Human viruses: Discovery and emergence. Phil Trans R Soc B 2012; 367: 2864–2871.
- Aguzzi A. Prion diseases of humans and farm animals: Epidemiology, genetics, and pathogenesis. J Neurochem 2006; 97: 1726–1739.
- Casanova JL, Abel L. The genetic theory of infectious diseases: A brief history and selected illustrations. Annu Rev Genomics Hum Genet 2013; 14: 215–243.
- Institute of Medicine (US) Forum on Microbial Threats. Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberg. In: Infectious Disease Emergence: Past, Present, and Future. Washington (DC): National Academies Press (US), https://www.ncbi.nlm.nih.gov/books/NBK45714/ (2009).
- Weston D, Hauck K, Amlôt R. Infection prevention behaviour and infectious disease modelling: A review of the literature and recommendations for the future. BMC Public Health 2018; 18: 1–16.
- Pinter-Wollman N, Jelic A, Wells NM. The impact of the built environment on health behaviours and disease transmission in social systems. Philos Trans R Soc B Biol Sci; 373. Epub ahead of print 2018. DOI: 10.1098/rstb.2017.0245.
- Koski-Karell V, Farmer PE, Isaac B, Campa E, Viaud L, Namphy P et al. Haiti’s progress in achieving its 10-year plan to eliminate cholera: Hidden sickness cannot be cured. Risk Manag Heal Policy 2016; 9: 87–100.
- Hutton G, Haller L, Bartram J. Economic and health effects of increasing coverage of low-cost household drinking-water supply and sanitation interventions to countries off-track to meet MDG target 10. Geneva, 2007. Epub ahead of print 2007. DOI: 10.2105/AJPH.75.9.1049.
- Mara D, Lane J, Scott B, Trouba, D. Sanitation and Health. PLoS Med 2010; 7: e1000363.
- Adane M, Teka B, Gismu Y, Halefom, G, Ademe, M . Food hygiene and safety measures among food handlers in street food shops and food establishments of Dessie town, Ethiopia: A community-based cross-sectional study. PLoS One 2018; 13: 1–13.
- Akabanda F, Hlortsi EH, Owusu-Kwarteng J. Food safety knowledge, attitudes and practices of institutional food-handlers in Ghana. BMC Public Health 2017; 17: 1–9.
- Jemal S. Knowledge and Practices of Hand Washing among Health Professionals in Dubti Referral Hospital, Dubti, Afar, Northeast Ethiopia. Adv Prev Med 2018; 10.1155/2018/5290797.
- Johnson RC, Boni G, Barogui Y, Sopoh G, Houndonougbo M, Anagonou E,Assessment of water, sanitation, and hygiene practices and associated factors in a Buruli ulcer endemic district in Benin (West Africa). BMC Public Health; 15. Epub ahead of print 2015. DOI: 10.1186/s12889-015-2154-y.
- Nair SS, Hanumantappa R, Hiremath SG, Siraj M, Raghunath P Knowledge, Attitude, and Practice of Hand Hygiene among Medical and Nursing Students at a Tertiary Health Care Centre in Raichur, India. ISRN Prev Med 2014; 2014: 1–4.
- Mohammadi M, Dalvandi A, Chakeri A. A study of handwashing training effects on awareness, attitude, and handwashing skills of third grade elementary school students. J Fam Med Prim Care 2020; 9: 1149.
- Shobowale E, Adegunle B, Onyedibe K. An assessment of hand hygiene practices of healthcare workers of a semi-urban teaching hospital using the five moments of hand hygiene. Nig Med J 2016; 57: 150.
- Sultana M, Alam Mahumud R, Razzaque Sarker A, Mahmud Hossain S,. Hand hygiene knowledge and practice among university students: Evidence from private universities of Bangladesh. Risk Manag Heal Policy 2016; 9: 13–20.
- Okojie OH, Wagbatsoma VA, Ighoroge AD. An assessment of food hygiene among food handlers in a Nigerian university campus. Niger Postgr Med J 2005; 12: 93–96.
- Zain MM, Naing NN. Sociodemographic characteristics of food handlers and their knowledge, attitude and practice towards food sanitation: a preliminary report – PubMed. Southeast Asian J Trop Med Public Heal 2002; 33: 410–417.
- Johnson PDR, Martin R, Burrell LJ, Grabsch E, Kirsa S, O’Keefe J, et al Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005; 183: 509–514.
- Braimoh BO, Udeabor SE. Hand hygiene practices among community Health Officers in Rivers State, Nigeria. Afri Heal Sci 2013; 13: 507–511.
- Iliyasu G, Dayyab FM, Habib ZG, Tiamiyu AB, Abubakar S, Mijinyawa M, et al. Knowledge and practices of infection control among healthcare workers in a Tertiary Referral Center in North-Western Nigeria. Ann Afr Med 2016; 15: 34–40.
- Iliyasu G, Dayyab FM, Abubakar S, Inuwa S, Tambuwal S, Tiamiyu A, et al. Laboratory-confirmed hospital-acquired infections: An analysis of a hospital’s surveillance data in Nigeria. Heliyon 2018; 4: e00720.
- Ige O, Asuzu M, Adesanmi A. Hospital-acquired infections in a Nigerian tertiary health facility: An audit of surveillance reports. Nig Med J 2011; 52: 239.
- Medical and Dental Council of Nigeria. Guideline on minimum standards of Medical and Dental education in Nigeria. Abuja, http://www.mdcnigeria.org/Downloads/Copy of Guideline on minimum standard-Red book.pdf (2006).
- Kulkarni V, Papanna MK, Mohanty U, Ranjan R, Neelima V, Kumar N, et al. Awareness of medical students in a medical college in Mangalore, Karnataka, India concerning infection prevention practices. J Infect Public Health 2013; 6: 261–268.
- Herbert VG, Schlumm P, Kessler HH, Frings A. Knowledge of and adherence to hygiene guidelines among medical students in austria. Interdiscip Perspect Infect Dis; 2013. Epub ahead of print 2013. DOI: 10.1155/2013/802930.
- Amin TT, Al Noaim KI, Bu Saad MA, Al Malhm T, Al Mulhim A, Al Awas M,et al. Standard precautions and infection control, medical students’ knowledge and behavior at a Saudi university: the need for change. Glob J Health Sci 2013; 5: 114–125.
- Cresswell P, Monrouxe L V. ‘And you’ll suddenly realise “I’ve not washed my hands”: Medical students’, junior doctors’ and medical educators’ narratives of hygiene behaviours. BMJ Open; 8. Epub ahead of print 2018. DOI: 10.1136/bmjopen-2017-018156.
- Shamseldin Elshafie S, Ibrahim A. Knowledge, awareness, and attitude regarding infection prevention and control among medical students: a call for educational intervention. Adv Med Edu Pr 2016; Volume 7: 505–510.
- Ojulong J, Mitonga KH, Iipinge SN. Knowledge and attitudes of infection prevention and control among health sciences students at University of Namibia. Afr Health Sci 2013; 13: 1071–1078.
- Bouwer M, Labuschagne S, Spamer S, Vermaak C, Zietsman L M, Steyn D, et al. Knowledge of final-year medical students at the University of the Free State of hand hygiene as a basic infection control measure. South African Fam Pract 2018; 60: 74–78.
- World Health Organization. WHO Patient Safety Curriculum Guide for Medical Schools. Geneva, 2009.
- Singh SP, Modi C, Patel C, Shah P. Introduction of infection control module for undergraduate medical students: experience at a rural medical college in India. Int J Infect Control 2014; 10: 1–8.
- World Health Organization. WHO guidelines on hand hygiene in health care (advanced draft): a summary. Geneva, 2005.
- Van De Mortel TF, Kermode S, Progano T, Sansoni J. A comparison of the hand hygiene knowledge, beliefs and practices of Italian nursing and medical students. J Adv Nurs 2012; 68: 569–579.
- Alharbi G, Shono N, Alballaa L, Aloufi A. Knowledge, attitude and compliance of infection control guidelines among dental faculty members and students in KSU. BMC Oral Health 2019; 19: 10.1186/s12903-018-0706–0.
- Snow M, White GL, Alder SC, Stanford J. Mentor’s hand hygiene practices influence student’s hand hygiene rates. Am J Infect Contr 2006; 34: 18–24.
- Onyedibe KI, Shehu NY, Pires D, Isa S, Okolo M, Gomerep S, et al. Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: A cross sectional study. Antimicrob Resist Infect Control 2020; 9: 1–9.
- World Health Organization. Hand hygiene for all initiative: improving access and behaviour in health care facilities, https://www.who.int/publications/i/item/9789240011618 (2020, accessed 1 December 2020).
- World Health Organization. Recommendations to Member States to improve hand hygiene practices to help prevent the transmission of the COVID-19 virus, https://www.who.int/publications/i/item/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the-transmission-of-the-covid-19-virus (2020, accessed 1 December 2020).
- Freedman M, Bennett SD, Rainey R, Otieno R, Quick R, . Cost analysis of the implementation of portable handwashing and drinking water stations in rural Kenyan health facilities. J Water Sanit Hyg Dev 2017; 7: 659–664.
- Sreenivasan N, Gotestrand SA, Ombeki S, Oluoch G, Fischer TK, Quick R, .. Evaluation of the impact of a simple hand-washing and water-treatment intervention in rural health facilities on hygiene knowledge and reported behaviours of health workers and their clients, Nyanza Province, Kenya, 2008. Epidemiol Infect 2015; 143: 873–880.
- Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich E. Bacterial contamination of health care workers’ white coats. Am J Infect Control 2009; 37: 101–105.
- Loh W, Ng V V., Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect 2000; 45: 65–68.
- Uneke CJ, Ijeoma PA. The potential for nosocomial infection transmission by white coats used by physicians in Nigeria: implications for improved patient-safety initiatives. World Heal Popul 2010; 11: 44–54.
- Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert R. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med 2011; 6: 177–182.
- Okeke EN, Ladep NG, Agaba EI, Malu AO. Hepatitis B vaccination status and needle stick injuries among medical students in a Nigerian university. Nig J Med 2008; 17: 330–332.
- Noubiap JJN, Nansseu JRN, Kengne KK, Tchokfe NS, Agyingi L. Occupational exposure to blood, hepatitis B vaccine knowledge and uptake among medical students in Cameroon. BMC Med Educ; 13. Epub ahead of print 2013. DOI: 10.1186/1472-6920-13-148.
- Asif M, Raza W, Gorar ZA. Hepatitis B vaccination coverage in medical students at a medical college of mirpurkhas. J Pakistan Med Assoc 2011; 61: 680–682.
- Machowicz R, Wyszomirski T, Ciechanska J, Mahboobi N, Wnekowicz E, Obrowski M, et al. Knowledge, attitudes, and influenza vaccination of medical students in Warsaw, Strasbourg, and Teheran. Eur J Med Res 2010; 15: 235–240.