A shot at stopping a virus - the Hepatitis B birth dose
Hepatitis B virus is a clever enemy. In most cases it silently invades its hosts, dormant until many years later in the form of liver disease or cancer. Infected women can get pregnant and unknowingly pass on the hepatitis B virus to their newborn infants during childbirth. In most Asian countries, one in 13 women of childbearing age has chronic hepatitis B infection. However, most low- and middle-income countries do not screen pregnant women for hepatitis B, making it impossible to distinguish who carries the virus and who doesn’t. The good news is that vaccinating newborn infants can prevent life-long infection.
We interviewed Dr Maria Asuncion Silvestre, a neonatologist at the University of the Philippines–Philippine General Hospital (UP-PGH) in Manila, Philippines. Having studied how best to care for newborn infants in their first hours of life after delivery, she is the convener of a project to scale up Essential Intrapartum and Newborn Care (EINC) that includes hepatitis B vaccination. This EINC scale-up takes place in hospitals and is an initiative of the Philippine Department of Health to reach Millennium Development Goals with support from the World Health Organization’s (WHO) Country Office in the Philippines. Even though it seems straightforward to vaccinate a newborn delivered in a hospital, experience in even the most evolved health care systems in the world shows that this may not be so clear-cut. Introducing any universal intervention into health care protocols, especially when it comes to newborn care, requires a well-defined plan.
We met at the Dr Jose Fabella Memorial Hospital in Manila, Philippines, one of the sites in the scale-up programme. Nicknamed “Manila’s baby factory", the centre delivers around 2000 babies a month. The women who fill the hospital’s halls hail from all over this sprawling metropolis. Most are women of limited financial means who walk in on foot, or are brought in by taxi, tricycle or jeepney. The cultures and conveyances may differ, but at its heart is a familiar scene that’s recognizable in busy public hospitals throughout the world.
A row of obstetric beds dominates the delivery ward of Fabella. Between that and the Neonatal Intensive Care Unit (NICU) sits an improvised vaccine refrigerator, padded with polystyrene and tape, and filled with water bottles to balance the temperature. A visit by the Department of Health immunization programme ensures that it stays at the temperature needed to keep the vaccines potent. Even in this most strained of settings, this hospital has worked to ensure prevention of one of the top killers in Asia by making sure every newborn gets vaccinated with the hepatitis B vaccine.
Drawing on the wealth of information afforded by several landmark studies carried out in the Philippines and other countries, the Department of Health was interested in knowing how and when to best administer vaccines and other vital interventions to newborn infants. “The focus of our investigation wasn’t just the birth dose of hepatitis B vaccine, but all the interventions carried out by health workers in the period surrounding delivery, particularly during those first minutes and hours after birth,” says Dr Silvestre when describing their research. “We found some inappropriate practices, including practices that should no longer be done and some that should be done but were not,” explains the neonatologist.
The researchers went into 51 hospitals and found 70% hepatitis B vaccination coverage. The hepatitis B vaccine is notable in that it is effective even after exposure to the virus from the mother during the birthing process. But the first dose needs to be given early – it is recommended for the first dose to be administered within 24 hours after birth, and then it must be followed by two more timely doses. To create awareness among mothers, the nurse or midwife administering the shot must let them know the purpose of the vaccine and that two more doses will be needed according to schedule.
Dr Silvestre affirms that rather than just getting hepatitis B birth dose coverage rates up, the EINC project is pushing vaccination in the context of time-sensitive, life-saving interventions. “Building on previous gains from birth-dose training initiatives, EINC is pushing the birthdose programme, not impeding it. Interventions should be synchronized and harmonized. When you talk about 2.4 million annual births all over the country, the chance that an intervention is missed goes up if you don’t put it in a discrete time band within a sequence.”
"In the past, midwives were wary to pass on tasks for the babies born on their shift to the next. Our time-motion studies were showing that babies would all be brought to a separate area to be weighed and vaccinated,” Dr Silvestre explains. “But now, the midwives move around with a tool box with all the necessary gear to give an injection." Practices have improved by lowering the risk of potential exposures that could occur in a common area and by keeping the newborn infants in a more comforted state with their mothers during vaccination.
In Dr Silvestre’s experience, teaching simple, practical tweaks to standard procedures or habits has an exponential effect on the national health care system when applied to the hospital setting. “In the 12 hospitals in the Department of Health programme now, we do saturation training in the workshops. We discuss all the interventions in the specific time bands they’re supposed to be performed in,” Dr Silvestre describes. “In a way, it’s mass training, and that’s every shift who handles babies and mothers.” No health worker is left behind: medical students from first years to interns, nursing students, staff at the NICU, the Emergency and Operating Room staff, and residents and consultants. They all learn EINC, whatever their place in the hospital hierarchy.
At Fabella, nurses and midwives are in charge of the delivery area; the nurse who gives the hepatitis B birth dose is also responsible for keeping the logbook, listing the newborn infants, and signing the charts. The number of birth doses given is reported to the National Immunization Programme at the Department of Health office from where the hospital gets their vaccine supply. Mothers are given a card with the baby’s name, weight, manner of delivery, and a list of vaccines given.
The Government recommends facility-based delivery; however, only 44% of births occur in facilities. Home delivery is a major challenge for the nine countries of WHO’s Western Pacific Region, including the Philippines, that are struggling to meet the regional milestone of reducing childhood chronic hepatitis B infection rates to less than 2%. In most of these countries, home deliveries are customarily handled by traditional birth attendants (TBAs), most of whom receive no formal training. “The Department of Health is maximizing efforts to engage these TBAs in community health teams as trackers and assistants so as not to deprive them of their livelihoods.”
The Philippines has shown great commitment towards hepatitis B control. Recently, in May 2011, President Aquino signed the Mandatory Infants and Children Health Immunization Act which includes that all infants should be given Hepatitis B vaccine within 24 hours of birth. In addition, Government of Philippines secures 100% of funds for procurement of hepatitis B vaccine rather than relying on donor support for funds. "Since it became a national policy, the hepatitis B birth dose is free and is included in the newborn care package. It’s lumped together with several things, such as vitamin K, eye care, and thermal care,” says Dr Silvestre. The package is free under PhilHealth, the Government’s social health financing mechanism. But even without PhilHealth coverage, essential newborn care interventions cost only around US$1, a pittance considering the pay-off.
National polices impact private practice because in this setting the family or private health maintenance organization pays for the vaccinations. “We do not have systematically collected data from private practice, but anecdotally, when the birth dose was first instituted, there was resistance from private practitioners in some hospitals because it was the hospital that would get the reimbursement and not the pediatrician,” Dr Silvestre says. “So babies under the care of some private practitioners were getting vaccinated after 24 hours, when they are seen for their check-up days later. As awareness of timely birth increased, this practice seems to have decreased significantly.”
Sometimes policy drives practice in unexpected ways or isn't implemented at all. Research in essential newborn care emphasizes the importance of getting to the field and making sure that public health policies translate into good practice. The campaign to ensure that no newborn acquires a life-long infection with the hepatitis B virus is one good example of this.