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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION. 1 NAME OF THE CANDIDATE Mr. SHINEDEV.T AND ADDRESS Ist YEAR MSc. NURSING STUDENT, N.D.R.K. COLLEGE OF NURSING B.M. ROAD HASSAN, KARNATAKA. 2 NAME OF THE INSTITUTION N.D.R.K. COLLEGE OF NURSING, B.M. ROAD, HASSAN, KARNATAKA. 3 COURSE OF STUDY AND SUBJECT 4 DATE OF MASTER OF SCIENCE IN NURSING (CHILD HEALTH NURSING) ADMISSION TO 15.06.2010 THE COURSE 5 TITLE OF THE TOPIC “EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF VIRAL HEPATITIS AMONG P.U STUDENTS IN SELECTED P.U COLLEGE AT HASSAN.” 5.1 STATEMENT OF THE “A STUDY TO EVALUATE THE EFFECTIVENESS OF PROBLEM STRUCTURED TEACHING PROGRAM ON KNOWLEDGE REGARDING PREVENTION OF VIRAL HEPATITIS AMONG P.U STUDENTS IN SELECTED P.U COLLEGE AT HASSAN.” 1 6. BRIEF RESUME OF THE INTENDED WORK 6.1. INTRODUCTION “An ounce of prevention is worth than a pound of cure” Benjamin Franklin Viral hepatitis is known as “inflammation of the liver” due to viral infection. It is a worldwide problem emerging from western as well as eastern part of the world including India. It occurs due to unhygienic practices, unsafe, poor environmental sanitation, etc. Viral hepatitis is most common in adolescents. The causative agents are the heterotrophic viruses (A, B, C&E). While hepatitis A&C transmitted through enteral route, hepatitis B&C transmitted through parentral route. It is necessary that everyone should be aware of the disease. The major challenge faced by the health care workers today is to provide awareness about hepatitis. So as to promote healthy behavior and thus be able to prevent disease.1 Hepatitis A is an acute infectious disease caused by hepatitis A virus. According WHO about 10- 50 person per 100,000 are affected annually. India, Bangladesh, Bhutan and Nepal demonstrated that 85-95% of children have been infected and are immune to hepatitis A virus infection by 10 years of age. Hepatitis A virus is very common, due to poor sanitation and environmental hygiene. Outbreaks of hepatitis A virus infection in urban settings are associated with drinking water and food. Hepatitis B infection is 66% of the entire world’s population living in areas where there high levels of infection. More than 2 billion people worldwide have evidence of past or current hepatitis B virus infection and 350 million are chronic carriers of virus. The carrier rate hepatitis B is high in general population (5-7%). In India alone there is an estimated 45 million. It is also estimated that 3% of world population is infected with hepatitis C virus and around 170 are chronic carriers in many countries particular population subgroups such as voluntary blood donors have very high prevalence of hepatitis C virus infection.1 Viral hepatitis A accounts for about 150,000 of the 500,000-600,000 new cases of viral hepatitis that occur each year in the United States. The hepatitis caused by hepatitis A virus is acute illness (acute viral hepatitis) that never becomes chronic. At one time, hepatitis A was referred to as “infectious hepatitis” because it could be spread from person to person like other viral infections.1 2 Nearly 200,000-300,000 new cases of viral hepatitis B infection each year in United States. Type B hepatitis at one time referred as “serum hepatitis” because it was thought that the only way hepatitis B virus spread was through blood and serum (liquid portion of the blood) containing the virus.1 Around 150,000 new cases of hepatitis C was reported each year. Type C hepatitis previously referred to as “ non-A, non-B hepatitis,” because the causative virus had not been identified, but it was known to be neither hepatitis A nor hepatitis B. the hepatitis C virus usually is spread by shared needles among drug users, blood transfusion, hemodialysis and needle sticks. Approximately 90% of transfusion associated hepatitis caused by hepatitis C.1 Hepatitis E virus is the etiological agent of non-hepatitis A virus enterically transmitted hepatitis. It is the major cause of sporadic as well as epidemic hepatitis, which is no longer confined to Asia and developing countries but has also become a concern of the developed nations. In the Indian subcontinent, it accounts for 30-60% of sporadic hepatitis.1 A study was conducted on “significant increase in hepatitis B virus, hepatitis C virus, human immunodeficiency virus and syphilis infections among blood donors in West Bengal, eastern India” to evaluate the prevalence of markers of hepatitis B virus, hepatitis C virus, human immune virus. Seroprevelance of hepatitis B surface antigen, anti- hepatitis C virus and anti-, human immune virus was studied among 113051 and 106695 voluntary blood donors screened in 2004 and 2005, respectively and a pilot study on 1027 HBsAg negative donors was carried out for evaluating the presence of hepatitis B virus (1448 vs 1768, P<0.001), human immune virus (262 vs 374 P < 0.001), hepatitis C virus (314 vs 372 P < 0.003) and syphilis ( 772 vs 853, P=0.001) infections was noted among blood donors of Kolkata West Bengal in 2005 as compared to 2004. Study reveals the significantly increasing endemicity of hepatitis viruses, syphilis and human immune virus among the voluntary blood donors.2 6.2. NEED FOR THE STUDY Viral hepatitis is a major public health problem all over the world. Approximately 152,000 cases of hepatitis A occur annually in United States and 10 million worldwide. Worldwide nearly 300 million peoples are infected with hepatitis B virus. 80,000 new cases of hepatitis B are estimated annually in United States. Worldwide approximately 170 million people are infected with hepatitis C virus. In the United States it is estimated that 4 million 3 individuals have been exposed, with 3 million of them chronically infected. Of these nearly 50% are not aware of their infection. Currently an estimated 25,000 new cases are diagnosed annually.3 A cross sectional sero-survey is done in four Pacific Island nations to determine the proportion of people previously infected with hepatitis A virus by measuring antibodies to hepatitis A virus (anti- hepatitis A virus). In American Samoa, 0.0% of 4-6 year olds (95% CI 0.0-3.7) were anti- hepatitis A virus positive. In Chunk, FSM, 8.6% of 2-6year olds (95% CI 5.711.5) were anti- hepatitis A virus positive compared with 98.3% of individual>/=16year old (95% CI 96.6-100). In Pohnpei, FSM 0.8% of 2-9 year olds (95% CI 0.0-1.6) were anti-HAV positive compared with 95.1% of >/=16 year olds (95% CI 92.2-98.0). In RMI, 85.7% (95% CI 81.9-89.5) of 4- 9 year olds were anti hepatitis A virus positive (95% CI 0.0-1.8). The low hepatitis A virus seroprevelance among children in American Samoa, FSM and Palau may indicate a vulnerability to hepatitis A morbidity among these populations. These data shows the need for hepatitis A surveillance and vaccination programs.4 Government of India reported that in India at least 100,000 people die every year due to illness related to HBV infection. Realizing the dangers of hepatitis B, the government expanded the Universal Immunization Program to include hepatitis B vaccine in the year 2002. This was done in 33 districts and 15 large cities with support of Global Alliance for Vaccines and Immunization, as a pilot project. According to pilot project report, 1.2 million children were vaccinated, with 3 dose of Hepatitis B. the Government plan to make reach of the vaccine nationwide by 2009.5 Indian current affairs (2010) reported regarding death due to water pollution in India from the period 2007 to 2009. It shows that acute diarrhrial disease is the primary cause of death and viral hepatitis is the secondary cause of death. According to this report, 30 deaths occurred at Karnataka due to viral hepatitis in the year 2009.6 A study was conducted on “epidemiological investigation of an outbreak of infectious hepatitis in Dakor town, Gujarat.” Epidemiological data collected from hospital records, active surveillance and the survey sample. The overall incidence rate of hepatitis E was found to be 18.76 per 1000 population. Similar finding was observed during the investigation of hepatitis 4 outbreak in Ahmadabad city during 1975-1976(the incidence rate of hepatitis E was 14 per 1000 population). Study shows that hepatitis E virus causes a major public health issue in India.7 According to Bangalore water supply department, 14,980 cases of viral hepatitis reported in the State in 2008, due to drinking contaminated water. A study was conducted on, “Uncertain knowledge: a national survey of high school students' knowledge and beliefs about hepatitis C” (2007) in Australia. In this study sample of students in Years 10 and 12 in government secondary schools (n = 3,550). Students' knowledge about HCV was found to be extremely poor. Of the seven questions on hepatitis, only one was answered correctly by more than half of the students. Few could differentiate between hepatitis A, hepatitis B and hepatitis C. Only a small number (12%) perceived themselves to be at risk of hepatitis and fewer than half (41%) had sought advice about hepatitis. The study concluded that there is a need of more hepatitis C virus education and health promotion for secondary school students.8 During the time of adolescence, after Pre University course people may go away from home for further studies. They will stay in risky circumstances like hostels, lodges, etc. Water and food supply on such condition may not be safe and this will cause hepatitis A and other communicable diseases. After Pre University course some of them go for medical and other allied courses. In hospital they are more prone to get needle stick injuries and other nosocomial infections. During adolescents some of them are willing to donate blood. This is also risk factor for hepatitis B and C. Sex attitude of adolescents are more than one sexual partner and homosexual activities may lead to hepatitis B, C and other sexually transmitted diseases. When adolescent people away from family members there is a chance to start alcoholism due to peer group influence. Alcoholism is one of the risk factor for hepatitis. So the investigator felt that providing knowledge to P.U students regarding prevention of viral hepatitis, will improve their knowledge and they will practice it in future life. Thus the threat of viral hepatitis can be reduced to large extend. 5 6.3. STATEMENT OF THE PROBLEM “A study to evaluate the effectiveness of Structured Teaching Program on Knowledge regarding Prevention of Viral Hepatitis among P.U students in selected P.U College at Hassan.” 6.4. OBJECTIVES OF THE STUDY 1. To assess the knowledge of P.U students regarding prevention of viral hepatitis before and after the administration of structured teaching program. 2. To Develop and administer structured teaching program regarding prevention of viral hepatitis among the P.U students. 3. To evaluate the effectiveness of structured teaching program by comparing pre-test and posttest knowledge scores regarding the prevention of viral hepatitis. 4. To associate the pretest and post test knowledge score of P.U students with selected socio – demographic variable. 6.5 HYPOTHESIS NULL HYPOTHESIS H0: There will not be any a significant difference between pre test and post test knowledge scores of who have received the structured teaching program on prevention of viral hepatitis. RESEARCH HYPOTHESIS H1: There will be a significant difference between pre test and post test knowledge scores of who have received the structured teaching program on prevention of viral hepatitis. H2: There will be significant association between selected socio demographic variables and knowledge of P U students. 6 6.6 ASSUMPTIONS 1. The P U students will be having less knowledge regarding viral hepatitis. 2. The P U students will be expressing willingness to learn and understand about viral hepatitis. 6.7 OPERATIONAL DEFINITIONS 1. EVALUATE It is the process of judging the value or quality of study regarding prevention of viral hepatitis before and after implementation of Structured Teaching Program. 2. EFFECTIVNESS It refers the significant gain in difference between pre test and post test knowledge and practice scores. 3. HEPATITIS Hepatitis is the inflammation of liver cells caused by hepatitis virus. 4. KNOWLEDGE It refers to the understanding of or information regarding viral hepatitis among P.U students of selected P.U College, Hassan. 5. STRUCTURED TEACHING PROGRAM It refers to systematically organized instruction (power point presentation) on knowledge regarding viral hepatitis. 6. SELECTED P. U COLLEGE It refers The Krishna P.U College at Hassan 7. P.U STUDENTS P.U students are those who studying P.U College with age between 15-17 years. 7 6.8. CRITERIA FOR SAMPLE SELECTION Inclusion criteria 1. P.U students who are studying in selected P.U College at Hassan. 2. P.U students who are present at the time of study Exclusion criteria 1. P.U students who are not present during research study. 2. Students who are studying in high school. 6.9 LIMITATIONS OF THE STUDY Study is limited to: 1. 60 P.U students in a selected P.U College at Hassan. 2. A period of 4 -6 weeks 6.10. SIGNIFICANCE OF THE STUDY This study will increase the knowledge of P.U students regarding viral hepatitis. And it also paves the way for P. U students to gain knowledge regarding preventive measures of viral hepatitis. 6.11 CONCEPTUAL FRAME WORK Theoretical framework based on, “Ludwig Von Bertalanffy’s General System Theory” (1968) 6.12. REVIEW OF LITERATURE Review of literature is a key step in research process. Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. Before any research can be started whether it is a single study or an extended project, literature review s of previous studies and experiences related to proposed investigations should be done. 8 One of the most satisfying aspects of the literature review is the contribution it makes to the new knowledge, insight and general scholarship of the researcher. Review of literature divided into three according to global, national and regional studies GLOBAL: A study was conducted was conducted in Bangui, Central African Republic, Dried blood Spots from 801 adolescent high school and young adult university students were prepared by spotting a drop of whole blood (4 spots) from the same finger prick onto Whatman filter paper. The overall prevalence was 42.3% for antibody to hepatitis B core antigen, 15.5% for HBsAg of which 1.3% of HBsAg alone. HBV familial antecedents, sexual activity and socioeconomic conditions were the main risk factors of HBV infection encountered in the adolescents and young adults.9 A study was conducted for. “The analysis on HBV epidemical trend of people age <20 from rural areas of Zhaodong”. In this study serum samples were collected in 1986 and 2005 respectively. HBsAg, anti-HBs and anti-HBc of the sera with SPRIA were tested. HBsAg average positive rate of the people age <20 decreased from 8.5% in 1986 to 4.4% in 2005 (chi2 = 10.88, P < 0.01). The anti-HBs average positive rate increased to 43.1% in 2005 from 18.3% in 1986 (chi2 = 130.47, P < 0.01). The anti-HBc average positive rate decreased from 39.9% to 15.1% (chi2 = 122.18, P < 0.01). The HBV infectious background of the rural population in Zhaodong city is high and the HBV infection rate decreased obviously after Hepatitis B inoculation since 1986, but it is still higher than the state average rate. It indicated that the HBV prevention in this district needs to be enforced and improved.10 A study was conducted to find the prevalence and risk factors of hepatitis B and C virus infections in an impoverished urban community in Dhaka, Bangladesh. In this study from June 2005-November 2006, 1997 participants were screened for HBsAg, anti-HBc and anti-HCV, 738 (37%) were males with mean (SD) age of 24 (14) years. HBV-seropositivity was documented in 582 (29%) participants, 14 (0.7%) were positive for HBsAg, 452 (22.6%) for anti-HBc and 116 (5.8%) for both HBsAg and anti-HBc. Four (0.2%) participants were positive for anti-HCV and another five (0.3%) for both anti-HBc and anti-HCV. 96/246 (39%) family members residing at same households with HBsAg positive participants were also HBV-seropositive.11 9 A study was conducted on, “Hepatitis antibody profile of Royal Thai Army nursing students.” In this study a viral hepatitis serosurvey done on 381 nursing students in Bangkok; 360 (94%) were female. The mean age was 20 (+/-3.6) years, 143, 92, 86 and 59 students came from Thailand's Central, North, Northeast and South provinces, respectively. The overall prevalence of hepatitis A, B, C and E antibody in the students was 8.9%, 10.8%, 0.5% and 11.5%, respectively. The highest seroprevalence to hepatitis A was observed in cadets from the southern region of Thailand.12 A study was conducted to find, “the seroprevalence of hepatitis A among children of different socioeconomic status in Cairo”. This study was carried out during the 6 months of period October 2003 to March 2004 on 426 children aged 3-18 years from low socio economic areas and 142 from high socio economic areas. Seroprevelance was significantly higher with age. Seropositivity to anti hepatitis A virus antibodies was significantly higher among children with low and very low socioeconomic status, 90%, compared to children of high socioeconomic status. Among the children who participated from the health insurance clinic, seroprevelance of anti- hepatitis A virus antibodies was 86.2% overall, 85.3% among male and 86.9% females with no statically significant difference (P>0.05). In the high socioeconomic status group, overall prevalence of anti-HAV antibodies was 50.2%, also with no significant difference between males and females. A significantly higher prevalence of anti-hepatitis A virus in relation to age was observed in the low socio economic status children,64.3% among those < 6 years, 85.3% among those aged 6-10 years, and 90% among older children (≥11years) (p <0.05).13 A study was conducted on “Prevalence of hepatitis virus A, B and C markers according to geographical origin of medical students.” Antibodies against viral hepatitis A, B and C were evaluated in 221 students of medical school of Padua University born in countries different from Italy. Data compared with those measured in 362 students born in Veneto region and 87 students born in Centre-Southern Italy. The result showed a high, significant prevalence of positive antibodies against hepatitis A in students from Africa (94.7%), Asia (60.9%), centre southern America (60.9%) and East Europe (52.7%); in Italy the prevalence was significant in students from Central Southern Italy (19.5%). A high prevalence of hepatitis B antibody was observed in 33.3% of Africa students, in 22.6% of students from East Europe and in 12.5% of Asian and Central Southern American students. Finally infection with hepatitis C is sporadic and without a significant geographic distribution.14 10 A sero-epidemiological study was undertaken in 2003–2004 in general populations of Flanders, Belgium with purpose of obtain a clear picture of the prevalence of hepatitis A, B and C. In this study 4,058 blood samples were drawn and collected in 10 hospitals in Flanders. . The study group was representative for the Flemish population. For hepatitis A seroprevalence of 55.1% was found. In the non-Belgian residents, the HAV prevalence was significantly higher than in Belgians (62% versus 52%; χ2 = 8.05; p = 0.005). For hepatitis B, 9.9% of the study group showed serological evidence of hepatitis B markers: 6.9% of the participants was positive for anti-HBs/anti-HBc, 0.7% appeared to be HBsAg positive and 3.5% was solely anti-HBs positive. The prevalence of HBV markers in Belgians was 6.9%, significantly lower compared to the 13.4% among non-Belgians (χ2 = 14.05; p = 0.00018). 4055 serum samples were analyzed for hepatitis C serology by second generation anti-HCV tests. Anti-HCV was detected in 0.87% of the serum samples. No statistically significant difference was found in HCV prevalence between Belgians and non-Belgians. Results of this study should help policy makers in their decisions on the most appropriate hepatitis A and B vaccination strategy and on the most effective prevention strategy for hepatitis C.15 A study was conducted on, “knowledge and practice and attitude of Swedish travelers on prevention of travel related infectious disease.” Self administered anonymous questionnaires were distributed to Swedish travelers (n=957). A majority of travelers sought general information, 74% and travel health advice, 59% prior to departure. Most perceived vaccination as safe and effective, but only 40% and 3% of travelers reported adequate vaccine coverage against hepatitis A or hepatitis B, respectively the study states the need for further health education among travelers.16 A study was conducted on 2002 to find age specific seroprevalence on hepatitis A among school children in Central Tunisia. They assessed seroprevalence of HAV in Sousse in Central Tunisia. A total of 2,400 school children 5–20 years of age (mean ± SD age = 11.7 ± 3.5 years) were selected by two-stage cluster sampling and tested serologically for IgG antibody to HAV by using an enzyme-linked immunosorbent assay. The overall seroprevalence among this population was 60% (44%, in children < 10 years old, 58% in those 10–15 years of age, and 83% in those > 15 years of age.17 11 A study was conducted to find out, “Prevalence of Hepatitis A in Children and Adolescents in Adana, Turkey” on 1998. The study was carried out in 711 children and adolescents (355 male, 356 female) aged 2.1 to 16.5 years (mean age 8.3 years).The overall prevalence of anti-HAV was 44.4% (316/711). The prevalence increased with advancing age i.e. 28.8% (2.1-6 yr), 49.8% (6.1-12 yr), and 68% (12.1-16.5 yr) (P < 0.0001). Seroprevalence was significantly lower in children less than 6 years and belonging to higher socioeconomic status.18 NATIONAL: A study was conducted to find out outbreak of acute viral hepatitis due to hepatitis E virus in Hyderabad from March through August 2005. In this study five hundred and forty-six clinically and biochemically documented cases were screened for the hepatotropic viral markers, hepatitis A, B, C, and E by the ELISA method. In this study hepatitis E as the major cause of the outbreak (78.57%). Occasionally, mixed infection of HEV-HAV (5.31%) or HEV-HBV (0.91%) was detected in the present series of acute viral hepatitis. Seroanalysis of 546 serum samples from the outbreak revealed the presence of at least one seromarker of hepatitis in 534 (98 %) cases. Among the 546 patients studied, males outnumbered females with a ratio of 2.3:1. The most affected age-group was that between 15 and 25 years, with an incidence of 73% in males. We found a relative sparing of children below 10 years of age. Of the 13 pregnant women with AVH, 3 (23%) women who were in the third trimester had a fatal outcome. No untoward effects were observed in the remaining 10 HEV infected pregnant women during their follow-up.19 According to Wikipedia there is hepatitis B outbreak in early 2009 at Gujarat. The hepatitis B epidemic was spread in Midasa, northern Gujarat, India. Over 125 people were infected and up to 49 people were killed in the epidemic.20 REGIONAL: A study was conducted at a large multi-specialty military hospital located at Bangalore, India over a period of one and half years from 01 Jul 2003 to 31 Dec 2004. A total of 252 cases of acute hepatitis were seen during the period of study. Twenty eight cases were excluded due to various reasons. 224 cases of acute viral hepatitis were included in the study. There were 175 males and 49 females in the mean age group of 22.5 years. Hepatitis E was the commonest cause seen in 102 (45.5%), followed by hepatitis A in 74 (33%) and hepatitis B in 28 (12.5%) cases. There were only two cases of acute hepatitis C. Mixed infection was seen in 18 cases (A+E 16 12 cases, B+E and B+A in one case each respectively). Hepatitis A constituted 41.2% of all cases in the age group 11-20 years, followed by hepatitis E (35.3%). In the older age group, 21-30 years, hepatitis E was the commonest (52%) infection followed by hepatitis A (31.3%).21 A hospital based study was conducted on hepatitis E virus in St. John’s Medical College stated that a total of 569 serum samples were screened for hepatitis E virus between April 1997 and March 2000, by commercially available hepatitis E Immunoglobulin G capture enzyme linked immune sorbent assay. The diagnosis was invariably acute hepatitis for differential diagnosis of jaundice. The percentage of seropositivity was found to be 18.8% in confirmed hepatitis E cases.22 7. MATERIAL AND METHODS OF STUDY 7.1. SOURCES OF DATA The data will be collected from selected P.U students studying a in a selected P.U College at Hassan, Karnataka. 7.2. METHOD OF DATA COLLECTION Data will be collected by self administered questionnaire. 1. Research design Quasi experimental design with single group pre-test post-test research. Schematic plan of the study:Group Pretest Intervention Posttest A group of 60 P.U O1 X O2 students studying at selected P. U college at Hassan.(Single group) 13 Key:O1= Pretest knowledge of P.U students regarding prevention of viral hepatitis. X = Structured teaching program on prevention of viral hepatitis. O2 = Post test knowledge of P.U students regarding prevention of viral hepatitis. 2. Research setting: - Selected P.U College at Hassan, Karnataka 3. Population: - students studying in a selected P.U College at Hassan 4. Sample: - students who full fill the inclusion criteria. 5. Sample size: - 60 P.U students. 6. Sampling technique: - Probability sampling method by stratified random technique will be used for the study. 7. Collection of data-Data will be collected by using self administered questionnaires. 8. VARIABLES Independent variable Structured teaching program for P.U students regarding prevention of viral hepatitis. Dependent variable Knowledge of P.U students regarding prevention of viral hepatitis. Extraneous variable Age, sex, class of study, religion, type of family, place of residence, education of father, education of mother, mass media exposure, socioeconomic status 14 9. PLAN FOR DATA ANALYSIS Descriptive statistics Descriptive statistics include percentage, frequency, mean and standard deviation Inferential statistics It include paired‘t-test’ with chi- square test for the assessment of knowledge and to associate the socio demographic variable is planned . 10. PILOT STUDY 10% of sample size is planned for the pilot study. 11. ETHICAL CONSIDERATION 1. Does the study require any intervention to be conducted on P.U students? Yes 2. Has ethical clearance will be obtained from your institution? Yes 3. Has the consent been taken from selected P.U College? Yes 15 12. LIST OF REFERENCES (VANCOUVER STYLE) 1. Park K, “Text book of preventive and social medicine” 19th edition, Banarasidas Bhanot, Jabalpur 2007 Pp 173-178 2. B. Ataei etal, “Hepatitis E virus in Isfahan Province: apopulation based study” Int J Infect Dis, Jul, 2008 3. S.M Lewis, M M Heitkemper and S.H Dirkson’s “Text book of medical surgical nursing” 5th Edition, Mosby publishers, Philadelphia, 2005, Pp 1105-15 4. Fisher GE etal, “The epidemiology of hepatitis A virus infections in four Pacific Island Nations, 1995-2008”, Trans R Soc Trop Med Hyg. 2009 Jun 9 5. W.A Achvan etal, “Epidemology of hepatitis B, C and E viruses and Human immune Deficiency viruse infection in Tahuna, Sangihe-Talaud Archipelago, Indonesia” Intervirology, 2007, 50(6): Pp 408-11 6. Indian Current Affairs 2010 7. A bhagyalexmi, M Gadhavi and B S Bhavasar, “Epidemolgical investigation of an outbreak of infectious hepatitis in Dakor town” Indian Journal of Community Medicine, 2007;32(4) Pp 277-279 8. Lindsay J etal, “Uncertain knowledge: a national survey of high school students' knowledge and beliefs about hepatitis C” Aust N Z J Public Health. 2009 Apr; 23(2), Pp 135-9. 9. Komas NP etal, “The prevalence of hepatitis B virus markers in a cohort of students in Bangui, Central African Republic”, BMC Infect Dis. 2010 Jul 29; 10, Pp 226-228. 10. Wang F etal, “Analysis on HBV epidemical trend of people age <20 from rural areas of Zhaodong”, Zhongguo Ji Hua Mian Yi. 2010 Jun; 16(3), Pp211-3 16 11. Ashraf H etal “Prevalence and risk factors of hepatitis B and C virus infections in an Impoverished urban community in Dhaka, Bangladesh”, BMC Infect Dis. 2010 Jul 15; 10, Pp208-209. 12. Pilakasiri C etal, “Hepatitis antibody profile of Royal Thai Army nursing students” Trop Med Int Health. 2009 Jun; 14(6), Epub 2009 Mar 2, Pp 609-611. 13. Salama etal, “Seroprevalence of hepatitis A among children of different socioeconomic status in Cairo”, Eastern Mediterranean Health Journal, Volume 13 No. 6 November – December 2007. 14. M. Beggio etal, “Prevalence of hepatitis virus A, B and C markers according to geographical origin of medical students”. G Ital Med Lav Ergen, 2007, 29(3)Pp 745-7. 15. M. Beutels etal, “Prevalence of hepatitis A, B and C in the Flemish population”, European Journal of Epidemiology, 2006, Volume 13, Number 3, Pp 275-280. 16. A L Dahlgren, L DeRoo and R Steffen and R Steffin, “Prevention of travel related infectious Diseases; knowledge, practices and attitude of Swedish traveler” Scand J Infect Dis 2006; 38(11-12): Pp1074-80. 17. Amal Latieff etal, “Age specific seroprevalance of hepatitis A among school children in Central Tunisha” Am.J.Trop. Med.Hyg 2005 73(1) Pp 40-43. 18. Hacer Yapicioglu etal, “Prevalence of hepatitis a in children and adolescents in Adana, Turkey”, Indian Pediatrics 2002; 39, Pp 936-941. 19. P Sarguna etal, “Outbreak of acute viral hepatitis due to hepatitis E virus in Hyderabad” Year: 2007, Volume: 25, Issue: 4, Pp 378-382. 20. www.wikepedia.com 17 21. Nandi etal, “Spectrum of Acute Viral Hepatitis in Southern India”MJAF 2009 vol 65 No.1 Pp 7-9 22. B Mishra etal, “A hospital based study of hepatitis E by serology” Indian J Med Microbio. 2003, Apr-Jun; 21(2): Pp 115-117. 18