1. Hepatitis B and the Philippines Minal K. Patel, MD Medical Epidemiologist Global Immunization Division March 14, 2012 Center for Global Health

2. Overview  High endemnicity for hepatitis B: ~9% HBsAg  Vaccine introduced in 1991  National policy phased in approach 1998-2005 Monovalent Pentavalent  Birth dose nationally 2007 Monovalent  Current schedule: birth, 6, 14 weeks  Variable coverage due to supply/funding

3. National Coverage for HepB3 and Birth Dose

4. 2010 Birth Dose <24 hours Coverage ≤ 50% coverage 50%-80% coverage >80% coverage

5. 2010 Hepa1 Coverage ( 24) ≤ 50% coverage 50%-80% coverage 80-110% coverage >110% coverage

6. 2010 3-dose Hepatitis Coverage ≤ 50% coverage 50%-80% coverage >80% coverage

7. Proposed Evaluations of Hepatitis B Program  What is the impact of the program?  How do we improve the program, especially the low <24 hour coverage?

8. What is the Impact of the Hepatitis B Program?  Surveillance for most VPDs  Acute hepatitis usually asymptomatic so hard to track  Chronic outcomes (liver cancer, cirrhosis) take a long time to occur  Seroprevalence studies  Test children for HBsAg  Most chronic infections are acquired less than 5 years of age, thus should test children ≥5 years of age

9. Philippines Seroprevalence Study  Objective  Determine the current burden of disease of chronic hepatitis B  Evaluate if Philippines has met the WPRO goal  Study design  2500 children born in 2006-2007  Nationally representative 20 provinces  ~8 barangays  16 children/barangay (prelim)  Rapid test for HBsAg Finger prick (~50 ul blood)

10. HBsAg Rapid Test

11. Tentative Implementation Plan  Potentially in June 2012  House to house in each barangay  If positive  Inform family  Recommend rest of family gets tested and vaccinated if appropriate  Results will be available hopefully by quarter 3

12. How do We Improve the Program?  Birth dose coverage is very low in <24hr, currently 38%  Home births (58%) Much harder to reach within 24 hours Though if SBAs attend birth than should be vaccinated <24 hours o 20% of all births with SBA at home Doesn’t fully explain low coverage  Health facilities (42%) All facility births should be giving vaccine within 24 hours What are barriers to providing the vaccine within 24 hours?

13. Hospital Assessment  8 regions  I, II, III, IVA, V, VI, VIII, X  Chosen because <50% BD coverage within 24 hrs Population >90K (~4% cohort) Not in an insecure area % gap between BD and health facility/ SBA deliveries Priority area for DOH in 2010 as low coverage for routine immunization  3 provinces/region  Large population  Large discrepancy between 24 hour coverage

14. Facility Visits  7 facilities/province  1 DOH retained  1 provincial hospital  1 district hospitals  2 rural health units with lying in clinic  2 private lying-in delivery facility or private facilities  Tentative visits: April 9-20  Questionnaire  Are HF giving BD vaccination and if yes, how?  If not, why not?  Why every dose is not given in 24 hours even in a facility?  SBA BD activities  Assess other aspects of program that can impact population immunity Vaccine management Program monitoring and reporting Supervision  Visit supervisor and assess extent of supervision and barriers to supervision

15. Site Visits  Visited HF in Pampanga, CHD-III in March 2012  1 regional hospital  1 provincial hospital  2 RHUs  1 private lying-in  Objectives  Understand birth dose program in implementing HF

16. Findings  Regional Director  Unaware birth dose in schedule  Vaccine shortage x 6 months  Provincial EPI staff  Unable to conduct supervision due to understaffing

17. Regional Hospital  Give birth dose on discharge on delivery ward  Children vaccinated 7 days/week  Do not vaccinate transfers, premature, LBW newborns, NICU  Do not vaccinate those leaving early against medical advice  Lack of training on BD vaccination  Vaccine management  Follow multidose vial policy  Fridge 15C  Failure to monitor fridge temperature  Vaccine stored in shelf under freezer  Failure to report to PHO, PHO visits HF  No supervision  Poor recording: all doses given in hospital, regardless of timing are recorded as <24 hours

18. Provincial Hospital  Purchasing vaccine for Phil Health patients  Hospital not reimbursed if do not give entire newborn package  Give birth dose M-Sat in delivery ward <24 hr after birth  Do not vaccinate transfers, premature, LBW, ill infants  Good vaccine management  Following incorrect schedule: BD, 6, 10 weeks  No supervision  Good, accurate reporting  Record review: 89% 24 hours

19.  Vaccine offered automatically for free to PhilHealth patients  Choice to parents without PhilHealth  Costs 500 PHP  Refuse due to cost  referred to RHU  Delay due to families deliberating if can pay cost  Mothers stay 24 hours. Therefore is say no in HF, then dose >24 hr if given  Vaccinate at time of delivery  Do not vaccinate children to be transferred  Staff have never been trained  Vials stored in home fridge  No thermometer  Stored under freezer compartment Private lying-in Barangay health worker collects data monthly and brings to RHU Record review: 43% 24%, rest unvaccinated/referred

20. RHU #1 and #2  Give vaccine in delivery room soon after delivery  1 facility has lying-in separate from EPI Vaccine stored in lying-in  Do not give vaccine to LBW, transfers  Staff have been trained  1 facility with BEMONC staff  Variable supervision  1 facility reports doses given <7 days as <24 hours

21. Major Findings and Recommendations  Regional hospital: Vaccinate on admission; add vaccine to standing admission orders  Data reporting is variable by location.  Regional: all facility vaccinations are <24 hr  RHU: reports all vaccinations that are <7 days as <24 hour  Vaccination should be provided daily, including Sunday  Vaccination cards should be accurate and standard  Vaccination information should be given to mothers at antenatal visit (Republic Act No. 10152)  Private facilities: poorly trained in EPI  If possible, recommend incorporating relevant personnel from private facilities into trainings  Supervisory visits should be conducted at all facilities providing vaccine, but need to address possible barriers to supervision

22. Conclusions  Evaluate impact of program  Seroprevalence study  Improve birth dose program  Evaluate program  Suspect simple changes can dramatically improve facility coverage E.g. standing orders, improved reporting, admission vaccination