Immunization Focus - the GAVI quarterly

GRASSROOTS - March 2001

En Français

Introducing hepatitis B vaccine

As the first round of countries prepare to immunize children for the first time against hepatitis B, Scott Wittet shares some tips in advocacy, communication, and training from developing countries that have done it already

HEPATITIS B is a killer, taking the lives of 900,000 people each year. Chronic carriers of the virus can infect others and are at risk of developing serious liver disease later in life, including cancer. Fortunately, hepatitis B vaccine can prevent infection and the World Health Organization recommends that all children worldwide should receive it.

Global enemy: the estimated prevalence of hepatitis B by region

The vaccine has been available for decades, but many countries still cannot afford to use it. The partners of GAVI and the Vaccine Fund are working to change this situation.

PATH (the Program for Appropriate Technology in Health) worked on some of the earliest introduction programmes for hepatitis B vaccine in Asia and Africa, under the aegis of the International Task Force on Hepatitis B Immunization. Here, we share some lessons we learned over a decade about effective advocacy with decision-makers, communication with parents and caretakers, and the training of health staff regarding hepatitis B.

As with the introduction of any new vaccine, there are some general rules. Plan your strategies for communication and training ahead of time. Use research to investigate providers' and consumers' knowledge and behaviour – these data can guide the design of messages and information products. Coordinate with colleagues in all parts of the health care system that will be affected, and make sure that messages and materials for key audiences are consistent. Finally, parents report that their most reliable source of information about immunization is their health care provider, so it is important that providers be able to accurately explain hepatitis B, the vaccine, and the importance of immunizing children. Focus on improving communication between providers and consumers first, and then use other media to support those interpersonal efforts.

Here are some specific suggestions:

1. Overcome confusion among decision-makers, providers, and the public

Hepatitis, and hepatitis B immunization, are confusing subjects for both providers and parents. Here are some common sources of confusion:

Some health care providers are not aware that WHO recommends that all infants receive hepatitis B vaccine.
People are often confused about the differences between hepatitis B and other forms of hepatitis.
They are also confused about jaundice. It is important to avoid implying that jaundice is caused only by hepatitis B. For example, it is misleading to say, "Hepatitis B vaccination prevents jaundice", when, in fact, hepatitis B vaccination only prevents jaundice caused by hepatitis B.
Hepatitis B is not always considered a disease of children, because liver cancer may take years to develop. This can make it more difficult for parents to see the benefits of infant immunization.
Hepatitis B is transmitted in different ways in different places. In some countries, hepatitis B usually is transmitted to children when they are very young. But in other countries, infection tends to occur later in life, causing parents to question the necessity of immunizing a young child.
There can be confusion about whether adults need to be immunized. Again, the advice will be different for different countries.
Expect numerous rumours about the safety and efficacy of various hepatitis B vaccines. Sometimes misinformation is spread by those who may profit from it.

2. Use every opportunity to educate providers about hepatitis B

How you can do this most effectively depends on your situation, as the following examples show:

In Lombok, Indonesia, the government experimented with new systems for birth reporting and for the delivery of hepatitis B vaccine within the first week of life. Due to changes in the roles and responsibilities of various staff, special training was required throughout the project area.
But in the Philippines, fewer systemic changes were envisioned, so extra training sessions were not needed. Instead, the Department of Health made sure that hepatitis B information was disseminated through in-house publications, and that it was discussed at staff meetings and regional and national conferences. Staff training curricula were updated as well.

Make it clear: Thai manuals for vaccinators and community health workers

3. Design materials based on audience needs

In Lombok, audience research revealed that parents tended to have lower levels of education and that they held many traditional (non-medical) beliefs about disease causation. Taking this into account, the introduction team decided to keep educational messages simple and to focus primarily on parental behaviour (how many times to take the child for immunization) more than on scientific information about the disease or vaccine. In general this strategy worked well since all parents learned how to get their children immunized and more educated parents who had other questions could get additional information from their doctors.
In Thailand, parents in our research sample were more knowledgeable and so materials were designed to address more sophisticated questions. One special situation: many providers and consumers in Thailand were confused about the need for adult vaccination. Because most teenagers and adults in that country have already been exposed to hepatitis B virus, adult and teen vaccination does not provide much benefit. Helping parents and providers understand this became a key communication goal for the programme.

4. Don't waste resources on unnecessary materials

Evaluations in Indonesia and Thailand showed that mass distribution of expensive printed materials for parents was not cost-effective.

When resources are limited, concentrate on providing high-quality reference materials and training for your programme's doctors, nurses, vaccinators, and outreach workers.
If you find that give-away materials for parents are necessary, try to develop good quality flyers instead of colourful booklets. They are less expensive to print and distribute.

Hope for the future

In the decade since the first Task Force programmes, many countries have found ways to integrate hepatitis B immunization into their national programmes. Botswana, China, Egypt, Indonesia, The Philippines, South Africa, Thailand, Tunisia, and Zimbabwe are among the developing world nations that now routinely protect their children against hepatitis B. With assistance from the GAVI partner agencies and the Vaccine Fund, more than 30 additional countries are beginning introductory efforts.

There is one additional, and crucially important, opportunity that the GAVI partners must not let slip away: now is the time to give the "polio troops" a new mission in countries where National Immunization Days are phasing out. No one has been more successful than the Polio Eradication Initiative in mobilizing communities for health. Now that polio eradication efforts are winding down in many areas, staff and volunteers can broaden their efforts, focusing on improving routine immunization and other primary health care programmes.

Scott Wittet is Director for Advocacy, Communication, and Training at the Bill and Melinda Gates Children's Vaccine Program at PATH.

For more information about hepatitis B and immunization programmes, visit the Resource Center of the Bill and Melinda Gates Children's Vaccine Program at PATH website, http://www.ChildrensVaccine.org or contact the GAVI Secretariat c/o UNICEF, Palais des Nations, 1211 Geneva 10, Switzerland. Email: gavi@unicef.org

This is an edited version of a paper presented at the GAVI Partners' Meeting in Noordwijk, the Netherlands in November 2000. The full paper can be downloaded from http://www.childrensvaccine.org/html/ip_advocacy.htm

Immunization Focus March 2001 - Contents