Vaccination coverage, seroprotection, and perceived immunity to hepatitis B among medical students in Brazil: implications for occupational safety in medical education

Vaccination coverage, seroprotection, and perceived immunity to hepatitis B among medical students in Brazil: implications for occupational safety in medical education | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Vaccination coverage, seroprotection, and perceived immunity to hepatitis B among medical students in Brazil: implications for occupational safety in medical education Yuri Felix Brandão, Isabella Siqueira Oliveira, Letícia Colares de Carvalho, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9097389/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Hepatitis B remains an important occupational health concern for healthcare workers and medical students due to the risk of exposure to blood and body fluids during clinical training. Medical students begin clinical activities early in their training, which may increase exposure to biological risks, including infection with the hepatitis B virus (HBV). This study aimed to analyze vaccination status and immunological protection against hepatitis B among medical students from two universities in Fortaleza, Ceará, Brazil, as well as their perception of immunity and the performance of post-vaccination serological testing. Methods A cross-sectional study was conducted with 163 medical students from two universities in Fortaleza, Ceará, Brazil. Data were collected using a structured questionnaire including information on vaccination history, perception of immunity, and post-vaccination serological testing. Descriptive statistics were used to calculate absolute and relative frequencies. Associations between variables were assessed using Pearson’s chi-square test or Fisher’s exact test. Prevalence ratios (PR) with 95% confidence intervals were also calculated. Results Complete hepatitis B vaccination coverage (three doses) was reported by 81% of participants. Although 91% of students believed they were immune, only 23% reported having undergone post-vaccination serological testing. Among the 38 students who performed serology, 38% of fully vaccinated individuals had reactive anti-HBs results. A statistically significant association was observed between perceived immunity and performance of serological testing. Conclusions A relevant discrepancy was observed between self-reported vaccination coverage, perceived immunity, and effective serological protection among medical students. These findings highlight the importance of implementing institutional protocols for serological verification and integrating vaccination monitoring and biosafety education into undergraduate medical training. hepatitis B vaccination medical students occupational health seroconversion Background Hepatitis B remains an important occupational health concern for healthcare professionals and students due to the risk of exposure to blood and other body fluids during clinical activities. Medical students begin clinical training during the early years of their education, which may increase exposure to biological risks, including infection with the hepatitis B virus (HBV) [ 1 , 2 ]. HBV infection represents one of the major global public health challenges. It is estimated that approximately 296 million people live with chronic infection, with about 1.2 million new infections and approximately 820,000 deaths annually related to its complications [ 3 , 4 ]. In Brazil, despite the implementation of the National Immunization Program (PNI) and universal hepatitis B vaccination since 1998, the disease remains a relevant concern, particularly among healthcare workers and students [ 5 ]. HBV transmission occurs primarily through vertical transmission (from mother to child during childbirth) and through contact with infected blood or body fluids. Additionally, HBV maintains significant infectivity on dry surfaces, especially in the presence of blood or body fluids, and may remain detectable for several days. Reports indicate persistence of HBsAg antigen and viral DNA for extended periods under laboratory conditions. This high environmental stability is recognized in the medical literature as an important factor in nosocomial and occupational transmission [ 6 , 7 , 8 ]. In the context of medical education, this scenario becomes particularly relevant. During undergraduate training, students attend clinical environments and perform procedures such as blood collection, venipuncture, insertion of intravenous catheters, and suturing of minor wounds. These activities may expose students to potentially contaminated biological material. Needlestick injuries and exposure to sharp instruments remain one of the main routes of occupational exposure to HBV among students and healthcare professionals in training, especially during the early stages of clinical practice [ 2 , 9 , 10 , 11 ]. Hepatitis B vaccination is considered the most effective preventive measure against the virus and shows high rates of seroconversion in the general population [ 12 , 13 ]. However, the immune response may vary between individuals, and antibody levels may decline over time [ 14 , 15 ]. Therefore, evaluation of vaccine-induced immunity becomes particularly relevant in populations exposed to occupational risks. Some authors recommend serological testing 5 to 10 years after vaccination, as well as booster vaccination for individuals without adequate protection [ 14 ]. In this context, assessing vaccination status and immunological protection among medical students is essential for preventing occupational infections and monitoring adherence to vaccination strategies in this population undergoing healthcare training [ 1 , 2 ]. Thus, the present study aimed to analyze vaccination status and immunological protection against hepatitis B among medical students from two universities in Fortaleza, Ceará, Brazil, as well as to evaluate perceived immunity and the performance of post-vaccination serological testing in this population. Methods Study design This was a cross-sectional, descriptive, and analytical study conducted with medical students from two higher education institutions located in Fortaleza, Ceará, Brazil. Study population Students regularly enrolled in the medical course and aged 18 years or older were eligible to participate in the study. Participation was voluntary and required the signing of an informed consent form. Data collection Data were collected using a structured self-administered questionnaire containing information on age, sex, hepatitis B vaccination history, perceived immunity, and performance of anti-HBs serological testing. The questionnaire was developed by the authors specifically for this study (see Supplementary File 1 – Questionnaire for the full version). Variables The dependent variable analyzed was serological immunity status (reactive or non-reactive anti-HBs result). Independent variables included age, sex, completeness of the vaccination schedule, and perceived immunity. Statistical analysis Statistical analysis included descriptive and inferential statistics, with calculation of absolute and relative frequencies. Associations between variables were evaluated using Pearson’s chi-square test or Fisher’s exact test when appropriate. Prevalence ratios with 95% confidence intervals were also calculated. A significance level of 5% was adopted. Ethical approval The study was conducted in accordance with the principles of the Declaration of Helsinki and Brazilian Resolution 466/2012 of the National Health Council. The research was approved by the Research Ethics Committee of the University of Fortaleza under protocol number 6.689.258. Results A total of 163 medical students participated in the study, with a mean age of 21.4 years. A predominance of male participants was observed (61.3%). Vaccination status and perceived immunity Regarding hepatitis B vaccination status, 132 students (81.0%) reported having received the complete three-dose schedule, whereas 31 (19.0%) reported not completing the vaccination schedule. Concerning perceived immunity, 149 participants (91.0%) believed they were protected after vaccination, while 14 (9.0%) did not consider themselves immune. Performance of anti-HBs serology Only 38 students (23.3%) reported having undergone serological testing for detection of anti-HBs antibodies, while 125 (76.7%) had never performed the test. Association between vaccination schedule and serological result Among the 38 students who performed serological testing, 26 (68.4%) had received the complete three-dose vaccination schedule. Of these, 10 (38.5%) had reactive results, 15 (57.7%) had non-reactive results, and one participant (6.9%) did not know the result. Among the 12 students with incomplete vaccination who underwent serology, 5 (41.7%) had reactive results and 7 (58.3%) had non-reactive results. No statistically significant association was observed between complete vaccination and reactive serological results (χ² = 0.00; p = 1.00). Fisher’s exact test confirmed this result (p = 1.00). The prevalence ratio was 0.92 (95% CI: 0.41–2.10). Association between perceived immunity and serological testing A statistically significant association was observed between perceived immunity and performance of anti-HBs serology (χ² = 6.06; p = 0.0138). Fisher’s exact test confirmed the statistical significance (p = 0.0087). Among students who believed they were immune, 34.2% had undergone serological testing, whereas among those who did not consider themselves protected, 71.4% had performed the test. The prevalence ratio was 0.48 (95% CI: 0.32–0.71), indicating that students with perceived immunity were less likely to undergo serological testing. Discussion The results of this study reveal an important discrepancy between self-reported vaccination coverage, perceived immunity, and effective serological protection among medical students from two universities in Fortaleza, Ceará, Brazil. Although most participants reported complete vaccination schedules, the low rate of post-vaccination serological testing revealed significant gaps in immunity monitoring among this population undergoing medical training and exposed to occupational risk during clinical practice. The vaccination coverage of 81% for the complete three-dose schedule observed in this study is similar to that reported in other studies involving healthcare students. International studies have also demonstrated high hepatitis B vaccination coverage among healthcare students, although gaps remain in monitoring immunity and performing post-vaccination serological testing[1,2,16,17]. However, the finding that 91% of medical students believe they are immune, while only 23% underwent confirmatory serological testing, suggests a possible false sense of security. This misperception may compromise the adoption of appropriate preventive measures, such as repeating the vaccination schedule when necessary, and reinforces the importance of objectively verifying immunity through laboratory testing. This finding becomes even more relevant when considering that medical students are progressively exposed to occupational risks throughout their training. Studies have demonstrated a high frequency of occupational exposure to blood and body fluids during clinical education, often associated with incomplete vaccination coverage and low rates of post-vaccination serological testing [1,9]. The insertion of students into clinical environments, where they perform invasive procedures and have direct contact with blood and body fluids, increases the risk of exposure to bloodborne pathogens, including HBV. Studies also indicate that needlestick injuries remain relatively frequent among students and healthcare professionals in training, particularly during the early stages of clinical practice, when technical skills are still being developed [9,11,17]. In the Brazilian context, research conducted in different regions has demonstrated considerable variation in vaccination coverage and seroconversion rates among medical students [5,9, 10,19]. Studies conducted in southeastern and southern regions of the country report seropositivity rates between 65% and 85%, values significantly higher than those observed in the present study [10]. Although methodological differences between studies should be considered, this discrepancy may reflect factors such as differences in access to serological testing, variations in institutional vaccination monitoring policies, population characteristics, or the time elapsed since vaccination [4, 12, 14, 16]. Fortaleza represents an important center for medical education in northeastern Brazil, concentrating several higher education institutions that receive students from diverse socioeconomic and epidemiological backgrounds. In this context, understanding the immunization profile against hepatitis B among medical students becomes essential for supporting more effective institutional occupational health policies [5,9,19]. One of the most concerning findings of this study was the low proportion of reactive serology among fully vaccinated students who underwent testing. Only 38% of students with a complete vaccination schedule had reactive anti-HBs results, a value lower than expected according to international literature, which reports seroconversion rates ranging from 90% to 95% in immunocompetent individuals after the full vaccination schedule. This result suggests that a significant proportion of students may not have detectable antibody levels at the time of serological assessment [4,9,12,13,15] . Several factors may influence the immune response to hepatitis B vaccination. Studies have demonstrated that seroconversion may be affected by individual characteristics such as age at the time of vaccination, sex, body mass index, smoking status, comorbidities, and genetic factors related to immune response [4,13,14,18]. In addition, the progressive decline of antibody levels over time is a widely documented phenomenon [12,13]. Although cellular immune memory may persist even in the absence of detectable antibodies, the lack of confirmatory serological testing makes it difficult to identify individuals who may remain susceptible to infection [14]. Another relevant finding observed in this study was the similarity between seropositivity rates among students with a complete vaccination schedule (38%) and those with incomplete vaccination (42%). Although the number of participants who performed serological testing was relatively small, this result suggests that self-reported vaccination alone may not guarantee effective immunological protection. This finding reinforces the importance of post-vaccination serological verification, particularly among populations at higher occupational risk [4,11]. The additional analysis conducted in this study also demonstrated a statistically significant association between perceived immunity and the performance of serological testing. Students who believed they were immune were less likely to undergo serological testing compared with those who did not consider themselves protected. This result suggests that subjective perception of immunity may reduce the search for laboratory confirmation, contributing to gaps in knowledge about the true immunological status of students. From an occupational health perspective, this finding is particularly relevant. Occupational exposure to the hepatitis B virus in academic environments represents not only an individual risk but also a concern for patient safety and the broader academic community [1,11]. Students susceptible to infection may acquire the virus during clinical activities and potentially contribute to transmission in healthcare environments. Given these findings, it becomes essential for medical schools to implement systematic strategies to monitor the vaccination and serological status of students. Verification of hepatitis B immunity before the beginning of clinical training should be considered a fundamental biosafety measure. Institutional protocols including post-vaccination serological testing, identification of non-responders, and provision of revaccination strategies may significantly reduce occupational risk. Studies have demonstrated that additional vaccine doses may restore immunity in a large proportion of individuals initially classified as non-responders [11,18]. Therefore, early identification of students who fail to achieve seroconversion allows preventive measures to be implemented before occupational exposure occurs. In addition to immunological monitoring strategies, health education plays a central role in preventing hepatitis B in academic environments. Educational interventions have been shown to significantly improve knowledge regarding hepatitis B and preventive measures among healthcare students and professionals [2,9,11]. This study has some limitations that should be considered when interpreting the results. The sample consisted of students from two institutions located in the same city, which may limit the generalization of the findings to other regions of the country. Furthermore, the low proportion of students who underwent serological testing may have introduced selection bias, as individuals who chose to perform the test may differ from those who did not. Finally, the cross-sectional design does not allow evaluation of temporal changes in antibody levels or the long-term durability of vaccine-induced immunity. Despite these limitations, the findings of this study contribute to expanding knowledge about hepatitis B immunization profiles among medical students in northeastern Brazil and reinforce the importance of implementing institutional policies for vaccination and serological monitoring. Future research should consider multicenter studies that allow comparison across different institutional and regional contexts, as well as investigations into factors associated with lack of vaccine response and evaluation of revaccination and serological monitoring strategies among medical students. Conclusions This study demonstrated a relevant discrepancy between self-reported hepatitis B vaccination coverage, perceived immunity, and effective serological protection among medical students from two universities in Fortaleza, Ceará, Brazil. Although most participants reported having completed the vaccination schedule and believed they were protected, the low rate of post-vaccination serological testing revealed an important gap in immunity monitoring within this population. The findings reinforce the need to implement institutional protocols for serological verification, adopt revaccination strategies when necessary, and strengthen biosafety education throughout medical training. These measures may contribute to reducing occupational risk, protecting students, and strengthening a culture of safety in academic healthcare environments. Abbreviations HBV Hepatitis B virus anti HBs—Antibody to hepatitis B surface antigen PNI National Immunization Program Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Research Ethics Committee of the University of Fortaleza, Ceará, Brazil, under approval number 6.689.258. All participants were informed about the objectives of the study and voluntarily agreed to participate by signing an informed consent form. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. The questionnaire used in this study is included as “Supplementary File 1 – Questionnaire”. Competing interests The authors declare that they have no competing interests related to this study. Funding This study did not receive specific funding from any public, commercial, or non-profit funding agencies. Authors’ contributions YFB, ISO, LCC, and JAB were responsible for data collection. SLS and SFRS performed the statistical analysis and supervised the study. All authors contributed to the study design, critically revised the manuscript, and approved the final version. Acknowledgements The authors thank the medical students who voluntarily participated in this study and the educational institutions that made this research possible. The authors acknowledge the use of ChatGPT (OpenAI, San Francisco, CA, USA) as a support tool for language editing and text organization during the preparation of this manuscript. All scientific content, interpretation of results, and final responsibility for the manuscript remain entirely with the authors. Author details ¹ School of Medicine, University of Fortaleza (UNIFOR), Fortaleza, Ceará, Brazil. Yuri Felix Brandão and Isabella Siqueira Oliveira are undergraduate medical students at this institution. Sônia Leite da Silva, PhD, is a faculty member at the University of Fortaleza. ² School of Medicine, Christus University (UNICHRISTUS), Fortaleza, Ceará, Brazil. Letícia Colares de Carvalho and Júlia de Araújo Baratta are undergraduate medical students at this institution. Silvia Fernandes Ribeiro da Silva, PhD, is a faculty member at both the University of Fortaleza and Christus University. References Noubiap JJN, Nansseu JRN, Kengne KK, et al. Occupational exposure to blood, hepatitis B vaccine coverage and attitudes toward hepatitis B virus infection among medical students in Cameroon. BMC Med Educ. 2013;13:148. https://doi.org/10.1186/1472-6920-13-148 . Özdemir L, Özyar SS, İsrafilzade S, Khorasani B. Occupational exposure to blood/body fluid and anxiety among final-year medical students: the result of curricular gaps in medical education. Int J Med Stud. 2025;13(Suppl 1). https://doi.org/10.5195/ijms.2025.3828 . World Health Organization. Global health sector strategies on HIV, viral hepatitis and sexually transmitted infections 2022–2030. Geneva: WHO; 2023. World Health Organization. Hepatitis B. Geneva: WHO; 2024. Brasil. Ministério da Saúde. Boletim epidemiológico: hepatites virais. Brasília: Ministério da Saúde; 2023. Than TT, Jo E, Todt D, et al. High environmental stability of hepatitis B virus and inactivation requirements for chemical biocides. J Infect Dis. 2019;219(7):1044–8. https://doi.org/10.1093/infdis/jiy620 . Hara J, Tanaka Y, Kaneko H, Itoh Y, Ikegaya H. Detection of hepatitis B virus DNA and HBsAg from postmortem blood and bloodstains. Arch Virol. 2018;163(3):633–7. https://doi.org/10.1007/s00705-017-3665-x . Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;6:130. https://doi.org/10.1186/1471-2334-6-130 . Oliveira LCM, Pontes JPJ. Frequency of hepatitis B immunity and occupational exposures to body fluids among Brazilian medical students at a public university. Rev Inst Med Trop Sao Paulo. 2010;52(5):247–52. https://doi.org/10.1590/S0036-46652010000500005 . Batista SM, Andreasi MS, Borges AM, et al. Soroprevalence of hepatitis B in medical students of a public university. Rev Soc Bras Med Trop. 2008;41(4):324–7. https://doi.org/10.1590/S0037-86822008000400003 . Panlilio AL, Cardo DM, Grohskopf LA, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001;50(RR–11):1–52. Banatvala J, Van Damme P, Oehen S. Lifelong protection against hepatitis B: the role of vaccine immunogenicity in immune memory. Vaccine. 2000;19(7–8):877–85. https://doi.org/10.1016/S0264-410X(00)00224-3 . Bruce MG, Bruden D, Hurlburt D, et al. Antibody levels and protection after hepatitis B vaccine: results of a 30-year follow-up study and response to a booster dose. J Infect Dis. 2016;214(1):16–22. https://doi.org/10.1093/infdis/jiw142 . Shen S, Ge S, Zhang Z, et al. Persistence of immunity in adults after 1, 5 and 10 years with recombinant hepatitis B vaccine in Beijing in 2010–2020. Vaccines (Basel). 2022;10(2):181. https://doi.org/10.3390/vaccines10020181 . Hanafi NF, Omar NN, Ismail GA, et al. Anti-HBs persistence and anamnestic response among medical interns vaccinated in infancy. Sci Rep. 2025;15:16213. https://doi.org/10.1038/s41598-025-00055-w . Baldolli A, Michon J, Verdon R, et al. Vaccination perception and coverage among healthcare students in France in 2019. BMC Med Educ. 2020;20:508. https://doi.org/10.1186/s12909-020-02426-5 . Centers for Disease Control and Prevention. Hepatitis B resources for health professionals. Atlanta: CDC; 2024. Zeeshan M, Jabeen K, Ali AN, et al. Evaluation of immune response to hepatitis B vaccine in health care workers in a tertiary care hospital in Pakistan: an observational prospective study. BMC Infect Dis. 2007;7:120. https://doi.org/10.1186/1471-2334-7-120 . Peres KA, et al. Vaccination coverage in Northeast Brazil during the pre-pandemic and pandemic periods: a descriptive study. Cien Saude Colet. 2025;29:142. https://doi.org/10.69849/revistaft/dt10202501261756 . Additional Declarations No competing interests reported. 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Medical students begin clinical training during the early years of their education, which may increase exposure to biological risks, including infection with the hepatitis B virus (HBV) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHBV infection represents one of the major global public health challenges. It is estimated that approximately 296\u0026nbsp;million people live with chronic infection, with about 1.2\u0026nbsp;million new infections and approximately 820,000 deaths annually related to its complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Brazil, despite the implementation of the National Immunization Program (PNI) and universal hepatitis B vaccination since 1998, the disease remains a relevant concern, particularly among healthcare workers and students [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHBV transmission occurs primarily through vertical transmission (from mother to child during childbirth) and through contact with infected blood or body fluids. Additionally, HBV maintains significant infectivity on dry surfaces, especially in the presence of blood or body fluids, and may remain detectable for several days. Reports indicate persistence of HBsAg antigen and viral DNA for extended periods under laboratory conditions. This high environmental stability is recognized in the medical literature as an important factor in nosocomial and occupational transmission [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the context of medical education, this scenario becomes particularly relevant. During undergraduate training, students attend clinical environments and perform procedures such as blood collection, venipuncture, insertion of intravenous catheters, and suturing of minor wounds. These activities may expose students to potentially contaminated biological material. Needlestick injuries and exposure to sharp instruments remain one of the main routes of occupational exposure to HBV among students and healthcare professionals in training, especially during the early stages of clinical practice [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHepatitis B vaccination is considered the most effective preventive measure against the virus and shows high rates of seroconversion in the general population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the immune response may vary between individuals, and antibody levels may decline over time [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, evaluation of vaccine-induced immunity becomes particularly relevant in populations exposed to occupational risks. Some authors recommend serological testing 5 to 10 years after vaccination, as well as booster vaccination for individuals without adequate protection [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, assessing vaccination status and immunological protection among medical students is essential for preventing occupational infections and monitoring adherence to vaccination strategies in this population undergoing healthcare training [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, the present study aimed to analyze vaccination status and immunological protection against hepatitis B among medical students from two universities in Fortaleza, Cear\u0026aacute;, Brazil, as well as to evaluate perceived immunity and the performance of post-vaccination serological testing in this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional, descriptive, and analytical study conducted with medical students from two higher education institutions located in Fortaleza, Cear\u0026aacute;, Brazil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents regularly enrolled in the medical course and aged 18 years or older were eligible to participate in the study. Participation was voluntary and required the signing of an informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a structured self-administered questionnaire containing information on age, sex, hepatitis B vaccination history, perceived immunity, and performance of anti-HBs serological testing. The questionnaire was developed by the authors specifically for this study (see Supplementary File 1 \u0026ndash; Questionnaire for the full version).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dependent variable analyzed was serological immunity status (reactive or non-reactive anti-HBs result). Independent variables included age, sex, completeness of the vaccination schedule, and perceived immunity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis included descriptive and inferential statistics, with calculation of absolute and relative frequencies. Associations between variables were evaluated using Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test when appropriate. Prevalence ratios with 95% confidence intervals were also calculated. A significance level of 5% was adopted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki and Brazilian Resolution 466/2012 of the National Health Council. The research was approved by the Research Ethics Committee of the University of Fortaleza under protocol number 6.689.258.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 163 medical students participated in the study, with a mean age of 21.4 years. A predominance of male participants was observed (61.3%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVaccination status and perceived immunity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding hepatitis B vaccination status, 132 students (81.0%) reported having received the complete three-dose schedule, whereas 31 (19.0%) reported not completing the vaccination schedule.\u003c/p\u003e\n\u003cp\u003eConcerning perceived immunity, 149 participants (91.0%) believed they were protected after vaccination, while 14 (9.0%) did not consider themselves immune.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerformance of anti-HBs serology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 38 students (23.3%) reported having undergone serological testing for detection of anti-HBs antibodies, while 125 (76.7%) had never performed the test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between vaccination schedule and serological result\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 38 students who performed serological testing, 26 (68.4%) had received the complete three-dose vaccination schedule. Of these, 10 (38.5%) had reactive results, 15 (57.7%) had non-reactive results, and one participant (6.9%) did not know the result.\u003c/p\u003e\n\u003cp\u003eAmong the 12 students with incomplete vaccination who underwent serology, 5 (41.7%) had reactive results and 7 (58.3%) had non-reactive results.\u003c/p\u003e\n\u003cp\u003eNo statistically significant association was observed between complete vaccination and reactive serological results (\u0026chi;\u0026sup2; = 0.00; p = 1.00). Fisher\u0026rsquo;s exact test confirmed this result (p = 1.00). The prevalence ratio was 0.92 (95% CI: 0.41\u0026ndash;2.10).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between perceived immunity and serological testing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA statistically significant association was observed between perceived immunity and performance of anti-HBs serology (\u0026chi;\u0026sup2; = 6.06; p = 0.0138). Fisher\u0026rsquo;s exact test confirmed the statistical significance (p = 0.0087).\u003c/p\u003e\n\u003cp\u003eAmong students who believed they were immune, 34.2% had undergone serological testing, whereas among those who did not consider themselves protected, 71.4% had performed the test.\u003c/p\u003e\n\u003cp\u003eThe prevalence ratio was 0.48 (95% CI: 0.32\u0026ndash;0.71), indicating that students with perceived immunity were less likely to undergo serological testing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study reveal an important discrepancy between self-reported vaccination coverage, perceived immunity, and effective serological protection among medical students from two universities in Fortaleza, Cear\u0026aacute;, Brazil. Although most participants reported complete vaccination schedules, the low rate of post-vaccination serological testing revealed significant gaps in immunity monitoring among this population undergoing medical training and exposed to occupational risk during clinical practice.\u003c/p\u003e\n\u003cp\u003eThe vaccination coverage of 81% for the complete three-dose schedule observed in this study is similar to that reported in other studies involving healthcare students. International studies have also demonstrated high hepatitis B vaccination coverage among healthcare students, although gaps remain in monitoring immunity and performing post-vaccination serological testing[1,2,16,17]. However, the finding that 91% of medical students believe they are immune, while only 23% underwent confirmatory serological testing, suggests a possible false sense of security. This misperception may compromise the adoption of appropriate preventive measures, such as repeating the vaccination schedule when necessary, and reinforces the importance of objectively verifying immunity through laboratory testing.\u003c/p\u003e\n\u003cp\u003eThis finding becomes even more relevant when considering that medical students are progressively exposed to occupational risks throughout their training. Studies have demonstrated a high frequency of occupational exposure to blood and body fluids during clinical education, often associated with incomplete vaccination coverage and low rates of post-vaccination serological testing\u0026nbsp;[1,9]. The insertion of students into clinical environments, where they perform invasive procedures and have direct contact with blood and body fluids, increases the risk of exposure to bloodborne pathogens, including HBV. Studies also indicate that needlestick injuries remain relatively frequent among students and healthcare professionals in training, particularly during the early stages of clinical practice, when technical skills are still being developed\u0026nbsp;[9,11,17].\u003c/p\u003e\n\u003cp\u003eIn the Brazilian context, research conducted in different regions has demonstrated considerable variation in vaccination coverage and seroconversion rates among medical students\u0026nbsp;[5,9, 10,19]. Studies conducted in southeastern and southern regions of the country report seropositivity rates between 65% and 85%, values significantly higher than those observed in the present study\u0026nbsp;[10]. Although methodological differences between studies should be considered, this discrepancy may reflect factors such as differences in access to serological testing, variations in institutional vaccination monitoring policies, population characteristics, or the time elapsed since vaccination\u0026nbsp;[4, 12, 14, 16].\u003c/p\u003e\n\u003cp\u003eFortaleza represents an important center for medical education in northeastern Brazil, concentrating several higher education institutions that receive students from diverse socioeconomic and epidemiological backgrounds. In this context, understanding the immunization profile against hepatitis B among medical students becomes essential for supporting more effective institutional occupational health policies\u0026nbsp;[5,9,19].\u003c/p\u003e\n\u003cp\u003eOne of the most concerning findings of this study was the low proportion of reactive serology among fully vaccinated students who underwent testing. Only 38% of students with a complete vaccination schedule had reactive anti-HBs results, a value lower than expected according to international literature, which reports seroconversion rates ranging from 90% to 95% in immunocompetent individuals after the full vaccination schedule. This result suggests that a significant proportion of students may not have detectable antibody levels at the time of serological assessment\u0026nbsp;[4,9,12,13,15]\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral factors may influence the immune response to hepatitis B vaccination. Studies have demonstrated that seroconversion may be affected by individual characteristics such as age at the time of vaccination, sex, body mass index, smoking status, comorbidities, and genetic factors related to immune response\u0026nbsp;[4,13,14,18]. In addition, the progressive decline of antibody levels over time is a widely documented phenomenon\u0026nbsp;[12,13]. Although cellular immune memory may persist even in the absence of detectable antibodies, the lack of confirmatory serological testing makes it difficult to identify individuals who may remain susceptible to infection\u0026nbsp;[14].\u003c/p\u003e\n\u003cp\u003eAnother relevant finding observed in this study was the similarity between seropositivity rates among students with a complete vaccination schedule (38%) and those with incomplete vaccination (42%). Although the number of participants who performed serological testing was relatively small, this result suggests that self-reported vaccination alone may not guarantee effective immunological protection. This finding reinforces the importance of post-vaccination serological verification, particularly among populations at higher occupational risk\u0026nbsp;[4,11].\u003c/p\u003e\n\u003cp\u003eThe additional analysis conducted in this study also demonstrated a statistically significant association between perceived immunity and the performance of serological testing. Students who believed they were immune were less likely to undergo serological testing compared with those who did not consider themselves protected. This result suggests that subjective perception of immunity may reduce the search for laboratory confirmation, contributing to gaps in knowledge about the true immunological status of students.\u003c/p\u003e\n\u003cp\u003eFrom an occupational health perspective, this finding is particularly relevant. Occupational exposure to the hepatitis B virus in academic environments represents not only an individual risk but also a concern for patient safety and the broader academic community\u0026nbsp;[1,11]. Students susceptible to infection may acquire the virus during clinical activities and potentially contribute to transmission in healthcare environments.\u003c/p\u003e\n\u003cp\u003eGiven these findings, it becomes essential for medical schools to implement systematic strategies to monitor the vaccination and serological status of students. Verification of hepatitis B immunity before the beginning of clinical training should be considered a fundamental biosafety measure. Institutional protocols including post-vaccination serological testing, identification of non-responders, and provision of revaccination strategies may significantly reduce occupational risk.\u003c/p\u003e\n\u003cp\u003eStudies have demonstrated that additional vaccine doses may restore immunity in a large proportion of individuals initially classified as non-responders\u0026nbsp;[11,18]. Therefore, early identification of students who fail to achieve seroconversion allows preventive measures to be implemented before occupational exposure occurs.\u003c/p\u003e\n\u003cp\u003eIn addition to immunological monitoring strategies, health education plays a central role in preventing hepatitis B in academic environments. Educational interventions have been shown to significantly improve knowledge regarding hepatitis B and preventive measures among healthcare students and professionals\u0026nbsp;[2,9,11].\u003c/p\u003e\n\u003cp\u003eThis study has some limitations that should be considered when interpreting the results. The sample consisted of students from two institutions located in the same city, which may limit the generalization of the findings to other regions of the country. Furthermore, the low proportion of students who underwent serological testing may have introduced selection bias, as individuals who chose to perform the test may differ from those who did not. Finally, the cross-sectional design does not allow evaluation of temporal changes in antibody levels or the long-term durability of vaccine-induced immunity.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, the findings of this study contribute to expanding knowledge about hepatitis B immunization profiles among medical students in northeastern Brazil and reinforce the importance of implementing institutional policies for vaccination and serological monitoring.\u003c/p\u003e\n\u003cp\u003eFuture research should consider multicenter studies that allow comparison across different institutional and regional contexts, as well as investigations into factors associated with lack of vaccine response and evaluation of revaccination and serological monitoring strategies among medical students.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrated a relevant discrepancy between self-reported hepatitis B vaccination coverage, perceived immunity, and effective serological protection among medical students from two universities in Fortaleza, Cear\u0026aacute;, Brazil. Although most participants reported having completed the vaccination schedule and believed they were protected, the low rate of post-vaccination serological testing revealed an important gap in immunity monitoring within this population.\u003c/p\u003e\n\u003cp\u003eThe findings reinforce the need to implement institutional protocols for serological verification, adopt revaccination strategies when necessary, and strengthen biosafety education throughout medical training.\u003c/p\u003e\n\u003cp\u003eThese measures may contribute to reducing occupational risk, protecting students, and strengthening a culture of safety in academic healthcare environments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatitis B virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eanti\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHBs\u0026mdash;Antibody to hepatitis B surface antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePNI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Immunization Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Research Ethics Committee of the University of Fortaleza, Cear\u0026aacute;, Brazil, under approval number 6.689.258. All participants were informed about the objectives of the study and voluntarily agreed to participate by signing an informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. The questionnaire used in this study is included as \u0026ldquo;Supplementary File 1 \u0026ndash; Questionnaire\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive specific funding from any public, commercial, or non-profit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYFB, ISO, LCC, and JAB were responsible for data collection.\u003cbr\u003e\u0026nbsp;SLS and SFRS performed the statistical analysis and supervised the study.\u003cbr\u003e\u0026nbsp;All authors contributed to the study design, critically revised the manuscript, and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the medical students who voluntarily participated in this study and the educational institutions that made this research possible.\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the use of ChatGPT (OpenAI, San Francisco, CA, USA) as a support tool for language editing and text organization during the preparation of this manuscript. All scientific content, interpretation of results, and final responsibility for the manuscript remain entirely with the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026sup1; School of Medicine, University of Fortaleza (UNIFOR), Fortaleza, Cear\u0026aacute;, Brazil.\u003c/p\u003e\n\u003cp\u003eYuri Felix Brand\u0026atilde;o and Isabella Siqueira Oliveira are undergraduate medical students at this institution.\u003c/p\u003e\n\u003cp\u003eS\u0026ocirc;nia Leite da Silva, PhD, is a faculty member at the University of Fortaleza.\u003c/p\u003e\n\u003cp\u003e\u0026sup2; School of Medicine, Christus University (UNICHRISTUS), Fortaleza, Cear\u0026aacute;, Brazil.\u003c/p\u003e\n\u003cp\u003eLet\u0026iacute;cia Colares de Carvalho and J\u0026uacute;lia de Ara\u0026uacute;jo Baratta are undergraduate medical students at this institution.\u003c/p\u003e\n\u003cp\u003eSilvia Fernandes Ribeiro da Silva, PhD, is a faculty member at both the University of Fortaleza and Christus University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNoubiap JJN, Nansseu JRN, Kengne KK, et al. 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Hepatitis B resources for health professionals. Atlanta: CDC; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeeshan M, Jabeen K, Ali AN, et al. Evaluation of immune response to hepatitis B vaccine in health care workers in a tertiary care hospital in Pakistan: an observational prospective study. BMC Infect Dis. 2007;7:120. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2334-7-120\u003c/span\u003e\u003cspan address=\"10.1186/1471-2334-7-120\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres KA, et al. Vaccination coverage in Northeast Brazil during the pre-pandemic and pandemic periods: a descriptive study. Cien Saude Colet. 2025;29:142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.69849/revistaft/dt10202501261756\u003c/span\u003e\u003cspan address=\"10.69849/revistaft/dt10202501261756\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"hepatitis B, vaccination, medical students, occupational health, seroconversion","lastPublishedDoi":"10.21203/rs.3.rs-9097389/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9097389/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHepatitis B remains an important occupational health concern for healthcare workers and medical students due to the risk of exposure to blood and body fluids during clinical training. Medical students begin clinical activities early in their training, which may increase exposure to biological risks, including infection with the hepatitis B virus (HBV). This study aimed to analyze vaccination status and immunological protection against hepatitis B among medical students from two universities in Fortaleza, Cear\u0026aacute;, Brazil, as well as their perception of immunity and the performance of post-vaccination serological testing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted with 163 medical students from two universities in Fortaleza, Cear\u0026aacute;, Brazil. Data were collected using a structured questionnaire including information on vaccination history, perception of immunity, and post-vaccination serological testing. Descriptive statistics were used to calculate absolute and relative frequencies. Associations between variables were assessed using Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test. Prevalence ratios (PR) with 95% confidence intervals were also calculated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eComplete hepatitis B vaccination coverage (three doses) was reported by 81% of participants. Although 91% of students believed they were immune, only 23% reported having undergone post-vaccination serological testing. Among the 38 students who performed serology, 38% of fully vaccinated individuals had reactive anti-HBs results. A statistically significant association was observed between perceived immunity and performance of serological testing.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA relevant discrepancy was observed between self-reported vaccination coverage, perceived immunity, and effective serological protection among medical students. These findings highlight the importance of implementing institutional protocols for serological verification and integrating vaccination monitoring and biosafety education into undergraduate medical training.\u003c/p\u003e","manuscriptTitle":"Vaccination coverage, seroprotection, and perceived immunity to hepatitis B among medical students in Brazil: implications for occupational safety in medical education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-15 06:20:31","doi":"10.21203/rs.3.rs-9097389/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-29T20:05:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T05:02:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129235480904202417288318639173801292961","date":"2026-04-13T17:41:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177110836725497687147051573574844357356","date":"2026-04-08T15:21:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T07:39:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T09:42:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T13:05:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-15T00:53:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-15T00:47:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b62e775-11aa-4b56-9c1f-187c79cbd1b8","owner":[],"postedDate":"April 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-04-29T20:05:24+00:00","index":66,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T06:20:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-15 06:20:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9097389","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9097389","identity":"rs-9097389","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}