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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.
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.
the estimated prevalence of hepatitis B by region
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
- 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
- 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.
3. Design materials based on
- 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
- 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
Evaluations in Indonesia
and Thailand showed that mass distribution of expensive printed
materials for parents was not cost-effective.
Make it clear: Thai manuals for vaccinators
and community health workers
- When resources are limited, concentrate
on providing high-quality reference materials and training
for your programme's doctors, nurses, vaccinators, and outreach
- 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,
or contact the GAVI Secretariat c/o UNICEF, Palais des Nations,
1211 Geneva 10, Switzerland. Email: email@example.com
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
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