A cross-sectional serosurvey among dental health professionals (dentists, nurses, residents and dental assistants) was conducted during May 2023 using a stratified multi-stage cluster design in five major cities of Georgia representing 42.5% of the 3.7 million Georgian population: Tbilisi (32.5%), Kutaisi (3.5%), Batumi (5.0%), Zugdidi (1.0%) and Telavi (0.5%). Based on an estimated 6.8% prevalence of anti-HCV among adults in the general population in 2021 [4], with a 2% margin of error, a population size of approximately 2000 DHPs in the five cities, and a 10% nonresponse rate, the calculated sample size was 519 participants.

Of 360 dental facilities operating in the five cities, 214 were randomly chosen using probability proportional to size sampling (PPS). Similarly, the number of participants to select per facility was determined by PPS. Participants in each facility were then selected using the Kish table method to ensure randomisation and reduce selection bias for a diverse group of certified DHPs [11].

A trained interviewer administered a questionnaire, through REDCap software, to participants compiling information on demographic characteristics and assessing knowledge, attitudes and practices related to hepatitis B and hepatitis C among DHPs. Knowledge regarding viral hepatitis was assessed across three categories: (1) general knowledge, (2) knowledge of modes of transmission and (3) knowledge of treatment and prevention.

Attitudes and perceptions were evaluated using questions that assessed dental health professionals’ concerns about contracting HBV and HCV infection from patients, their willingness to provide dental services to patients with these diseases, the perceived safety of the hepatitis B vaccine and perception of stigma associated with HBV and HCV infection in Georgia. Answers related to attitudes toward HBV and HCV infection were categorised as agree, neutral, disagree and don’t know.

The survey included 17 questions related to hepatitis B and hepatitis C practice and exposure among DHPs. These questions explored areas such as previous screening for HBV and HCV infection, hepatitis B vaccination, implementation of infection prevention and control measures in dental facilities including the use of protective gear and sterilisation of instruments, and practices related to the handling of used syringes and needles among dental health professionals.

After completing the questionnaire, blood samples were collected from study participants to test for hepatitis B and hepatitis C markers.

Serum samples collected from participants were tested for anti-HCV using the anti-HCV chemiluminescent microparticle immunoassay on a fully automated ARCHITECT i2000SR analyser (Abbott Diagnostics), and total anti–HBc using the chemiluminescence microparticle immunoassays ARCHITECT Anti-HBc II (Abbott Diagnostics, Wiesbaden and Germany). Anti-HCV reactive samples were tested for HCV RNA using the Xpert HCV Viral Load Assay (Cepheid AB). Total anti-HBc reactive samples were tested for hepatitis B surface antigen (HBsAg) by the ARCHITECT HBs Ag Qualitative A II (Abbott Diagnostics, Sligo and Ireland). Additionally, HBsAg reactive samples were tested for the presence of immunoglobulin G class antibody to hepatitis D virus (anti-HDV).

Negative test results were sent to participants via text message. Persons with any positive test result for HBV or HCV were contacted via phone by staff from the National Centre for Disease Control and Public Health (NCDC) and post-test counselling was provided, including referral to a local healthcare provider for further assessment and treatment initiation.

Descriptive statistics were calculated to summarise participants’ characteristics and prevalence of infection. Categorical variables are presented as frequencies and percentages, while continuous variables are presented as means, medians, standard deviations (SD) and interquartile ranges (IQR).

Knowledge and practice scores were evaluated using a point system, with one point awarded for each correct answer. For knowledge, the total possible score for HBV and HCV was 24 for each. The maximum score for practice was 19, assessed using a similar point system. High knowledge score was defined as having at least 17 (≥ 70%) correct responses out of 24. High practice score was defined as having at least 14 (≥ 73%) correct responses out of 19.

Linear regression models were used to identify associations between the knowledge and practice scores and demographic and professional characteristics from adjusted means differences with 95% confidence intervals (95% CI). Variables with p < 0.2 in the bivariate linear regression were included in the multivariable model. Multivariable logistic regression analysis assessed factors associated with high knowledge score (≥ 17 out of 24 points) for hepatitis B and hepatitis C and included all variables with p < 0.2 in bivariate logistic regression. Variables were assessed for multicollinearity prior to inclusion in the regression models. All linear and logistic regression models included age, sex, profession, place of work, work experience and salary; the linear regression model for practice scores also included hepatitis B vaccination status. Significance was set at p < 0.05. Data were analysed using STATA 18 and SAS version 9.4.

The study was approved by the Institutional Review Board of the National Centre for Disease Control and Public Health, Georgia (registration number for IRB # 2023–024). The U.S. CDC determined the study to be human subjects research in which CDC staff were not engaged.

Of 519 DHPs who participated, 436 (84.0%) were female, and 329 (63.4%) were aged 30–49 years. The region of dental practice followed the regional population distribution, with 81.3% practicing in the capital, Tbilisi. The majority were dentists (76.1%), followed by nurses (15.4%). The majority (65.6%) had 10 or more years of dental work experience, and 45.7% reported a monthly salary of 500–1000 Georgian Lari (GEL; approximately 190–381 U.S. dollars [USD]) (Table 1).

Serum samples were collected for 518 participants with one participant declining and one sample drawn as excluded due to hemolysis. Among the 517 tested, 4 (0.8%) were reactive for anti-HCV; none were HCV RNA positive. Additionally, 63 (12.2%) were total anti-HBc reactive, and 3 (0.6%) were HBsAg reactive; none were anti-HDV positive. One sample was reactive for anti-HCV and anti-HBc and not reactive for HBsAg.

Almost 95% of DHPs reported that healthcare workers and dentists are at a high risk of exposure to HBV and HCV. Approximately a third were able to identify all listed groups at risk for HBV (36.4%) and HCV (35.3%) infection (Table 2).

The majority correctly identified blood as a potential source of HBV (95.2%) and HCV (97.1%) infection, while sharing needles or syringes was identified as a potential source by 75.0% for HBV and 78.4% for HCV. Sexual contact was identified as a source of transmission by 58.0% and 54.9% of respondents for HBV and HCV, respectively. Fewer respondents identified sharing household objects like razors or toothbrushes (38.0% for HBV and 41.2% for HCV), and mother-to-child transmission (21.4% for HBV and 24.1% for HCV). Some participants had misconceptions on modes of transmission of HBV and HCV, with nearly one in five reporting that HBV (19.7%) and HCV (16.0%) are transmitted by respiratory droplets. Overall, 6.6% and 7.9% of participants correctly identified all modes of transmission of HBV and HCV, respectively. While 79.6% correctly reported that HCV infection can be cured, only 26.8% knew that HBV cannot be cured. The majority (77.8%) stated that hepatitis B is preventable by vaccination, while 42.8% knew that there was no vaccine for hepatitis C (Table 2).

Overall, participants had a median knowledge score of 16 (IQR 14–19) out of a maximum 24 points for HBV and 17 (IQR 14–19) of 24 correct answers for HCV. Overall, 49.1% and 51.1% of participants had a high knowledge score for HBV and HCV, respectively.

Overall, 70% of DHPs reported that persons with hepatitis B or hepatitis C in Georgia face stigma due to their infection. More than half of participants stated that it is essential for them to receive the hepatitis B vaccine as healthcare providers (56.3%) and 55% reported that the hepatitis B vaccine was safe. The majority of respondents indicated they would conduct dental procedures on patients with HBV (93.3%) and HCV (92.3%), while 45.5% and 46.1% were concerned about getting HBV or HCV from their patients, respectively (Figure 1).

Of 519 dental health professionals, 41.6% reported ever experiencing a blood splash on the face, 43.7% reported a previous needle-stick injury and 20.6% reported being previously injured with a contaminated instrument (Table 3). The majority reported being screened for HBV (83.4%) and HCV (90.8%), while 23.9% reported having been vaccinated against hepatitis B. Most (60.3%) DHPs routinely ask patients about their HBV and HCV status, and 18% reported changing their behaviour with patients having hepatitis B or hepatitis C.

The majority (97.7%) always wear gloves during patient care, and among them 99.4% properly dispose of the gloves afterward. Overall, 64.9% and 83.4% reported always using protective eyewear and clothing, respectively; 88.2% used new protective covers for each patient and 96.5% said they do not reuse single-use instruments. Additionally, 95.6% reported always washing their hands before and 95.0% after examining patients. Only 59.5% of respondents reported cleaning all required areas with disinfecting solutions, and 76.1% directly disposed of used needles and syringes in sharp containers, while 10.4% reported leaving the used syringes uncapped on surfaces for maintenance staff (Table 3).

Of the 519 interviewed DHPs, the median total correct practice score was 17 [IQR 15–18] out of 19 possible correct answers. The majority had a high practice score (89.4%), answering ≥ 14 questions correctly.

The analysis of both knowledge and practice scores among DHPs in Georgia’s five cities through multivariable linear regression highlights several key findings (Table 4).

Participants’ age and sex were not associated with knowledge or practice scores. However, compared to dentists, nurses had lower mean knowledge scores for hepatitis B (adjusted means difference [aβ]: −1.2 [95% CI: −2.0, −0.3]), and hepatitis C (aβ: −1.2 [95% CI: −2.1, −0.4]) and lower practice scores (aβ: −1.9 [95% CI: −2.5, −1.2]). Compared to dental health professionals in Tbilisi, knowledge scores were higher among those in Batumi for hepatitis B (aβ: 1.4 [95% CI: 0.5, 2.3]) and hepatitis C (aβ: 1.5 [95% CI: 0.6, 2.3]), but lower in the city of Zugdidi for both hepatitis B (aβ: −2.4 [95% CI: −3.8, −0.9]) and hepatitis C (aβ: −2.7 [95% CI: −4.2, −1.3]). Participants in Kutaisi also had a lower hepatitis C mean knowledge score than those in Tbilisi (aβ: −1.7 [95% CI: −3.1, −0.3]). For practice scores, compared to Tbilisi only those in Telavi had a significantly lower mean score (aβ: −2.5 [95% CI: −4.4, −0.7]). Having a higher salary (> 2000 GEL [> 763 USD]) per month was also associated with a higher mean knowledge score for hepatitis B (aβ: 1.7 [95% CI: 0.4, 3.0]) and hepatitis C (aβ: 1.6 [95% CI: 0.4, 2.9]), and higher practice score (aβ: 1.0 [95% CI: 0.1, 2.0]) compared to those making < 500 GEL (< 190 USD) per month. Practice scores were lower among dental health professionals who had not been screened for hepatitis B (aβ: −1.3 [95% CI: −2.1, −0.5]) or had not been vaccinated against hepatitis B (aβ: −1.3 [95% CI: −1.8, −0.9]) compared to those who had been screened or vaccinated.

In the multivariable logistic regression, DHPs in Batumi were twice as likely to have a high knowledge score for hepatitis B (aOR 2.12 [95% CI: 1.08, 4.15]) compared to those in Tbilisi, while those in Zugdidi were significantly less likely to have high knowledge score for both hepatitis B (aOR 0.08 [95% CI: 0.01, 0.63]) and hepatitis C (aOR 0.07 [95% CI: 0.01, 0.55]) (Table 5). Participants in Kutaisi were also less likely to have a high knowledge score for hepatitis C (aOR 0.05 [95% CI: 0.01, 0.35]) compared to those in Tbilisi. Nurses were half as likely as dentists to have a high knowledge score for hepatitis B (aOR 0.53 [95% CI: 0.29, 0.99]) and hepatitis C (aOR 0.53 [95% CI: 0.29, 0.97]). Finally, participants earning > 2000 GEL per month (> 763 USD) had more than 3 times the odds of having a high knowledge score for both hepatitis B (aOR 3.21 [95% CI: 1.25, 8.23]) and hepatitis C (aOR 3.25 [95% CI: 1.28, 8.27]) compared to those earning < 500 GEL (< 190 USD) per month.

Assessment of collinearity between age and work experience indicated it was not a major concern, with a condition index of 15.4 and a variance inflation factor of 4.1. Both variables were retained to capture potentially distinct effects of chronological age and years of practice on knowledge and practice outcomes.