Susceptibility of healthcare workers in Kenya to hepatitis B: new strategies for facilitating vaccination uptake

doi:10.1016/j.jhin.2006.06.024

Journal of Hospital Infection

Volume 64, Issue 3, November 2006, Pages 271-277

https://doi.org/10.1016/j.jhin.2006.06.024 Get rights and content

Summary

Hepatitis B virus (HBV) infection is preventable, yet many healthcare workers (HCWs) in resource-poor countries remain at risk. The aims of this study were to evaluate the susceptibility of HCWs in a Kenyan district to HBV infection, and the feasibility of expanding the Extended Programme of Immunization (EPI) for infants to incorporate hepatitis B vaccination of HCWs. HCWs in Thika district, Kenya were invited to complete an interviewer-administered questionnaire about their immunization status and exposure to blood or body fluids. Participants were asked to provide a blood sample to assess natural or vaccine-induced protection against HBV. All non-immune HCWs were offered hepatitis B vaccination. Thirty percent (168/554) of HCWs reported one or more needlestick injuries (NSIs) in the previous year, with an annual incidence of 0.97 NSIs/HCW/year. Only 12.8% (71/554) of HCWs had received vaccination previously and none had been screened for immunity or for hepatitis B surface antigen. In total, 407 staff provided blood samples; 41% were HBV core antibody, 4% expressed hepatitis B surface antibody from previous vaccination, and 55% were unprotected. Two hundred and twenty-two staff were eligible for vaccine delivered through the EPI infrastructure. Self-motivated uptake of a full course of vaccine was 92% in the smaller health centres and 44% in the district hospital. This study demonstrates the importance of hepatitis B vaccination of HCWs in parts of Africa where high exposure rates are combined with low levels of vaccine coverage. High rates of vaccination can be achieved using childhood immunization systems for the distribution of vaccine to HCWs.

Section snippets

Background

Hepatitis B virus (HBV) infection has been preventable by vaccination since the early 1980s. Despite being safe, efficacious and cost-effective, hepatitis B vaccination is still consistently underutilized.1, 2 Approximately 88% of the world's population live in areas where the prevalence of chronic HBV infection is moderate to high.³ For such countries, the Global Advisory Group in 1991 recommended the incorporation of hepatitis B vaccine into the routine Extended Programme of Immunization

Site

The study was undertaken in Thika, a typical Kenyan district situated 60 km north of Nairobi. It has two government hospitals and nine primary healthcare centres serving an estimated population of 700 000.²⁰ The HIV seroprevalence rate in the district has been reported to be 9–11%.²¹ In 2002, when the study commenced, there was no district system for administration of hepatitis B vaccine or for reporting NSIs, and no PEP for HIV. The cold chain for childhood immunizations was maintained by

Results

In total, 650 HCWs were at risk of NSIs in the district (496 permanent positions, 100 nursing students on placement, and 54 casual and day labourers). Interviews were conducted with 554 staff, with 72 exclusions (permanent night shifts, long-term leave, and transfers out of the region) and 24 HCWs declining to be interviewed. Study participation, serological results and vaccine uptake are summarized in Figure 1. Of the interviewees, 78% were female and 63% were nurses, similar to the overall

Discussion

This study demonstrates to policymakers the ongoing need for hepatitis B vaccination in resource-poor settings where high exposure rates are combined with low levels of vaccine coverage. It also demonstrates the feasibility and acceptability of the childhood EPI infrastructure for the distribution and administration of vaccine to HCWs. Vaccination was conducted without any additional incentives to staff administering or receiving vaccination.

Study participation was high. Eighty-five percent of

Acknowledgements

This paper was published with the kind permission of the Director of KEMRI (Kenya Medical Research Institute). The authors are grateful to the District Health Management Team and the staff of Thika district in Kenya. In particular, the authors wish to thank Mrs Priscilla Mbiyu, who is in charge of vaccines at the district hospital, for her dedication and professionalism in this task. The authors would also like to thank the laboratory technicians of the KEMRI Centre for Virology Research.

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Cited by (39)

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Health workers (HW) are at risk of contracting vaccine preventable diseases when caring for patients and communities. This study aims to evaluate the existing literature on the routine vaccination of health workers against a variety of antigens in low and middle income countries, focusing on facilitators, barriers, and considerations in the implementation of immunization programs and campaigns.
A PubMed Literature search.
A PubMed search was conducted to find articles that addressed vaccination programs and policies for HW in low-income countries (LIC), lower middle-income countries (LMIC), and upper middle-income countries (UMIC). Original articles, meta-analyses, and reviews published in English between January 2000 and July 2022 were included in the search. Inductive content analysis was used to identify themes that illustrate facilitators, barriers, and considerations in the implementation of immunization programs and campaigns.
The search identified 4240 studies, 90 were used for analysis as they provided antigen specific details on immunization policies or programs. Hepatitis B was the most frequently discussed antigen, followed by Influenza, then Measles, Rubella and Mumps. With considerable variability by vaccine and country, in most cases the vaccination was not offered free to HW or included in a regular vaccination schedule. Utilizing existing immunization infrastructure such as the Expanded Programme on Immunization (EPI) and having effective management of vaccination programs were found to be key facilitators to vaccinate HW.
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Citation Excerpt :
None of the studies in our sample compared the strategies in terms of cost, uptake, or other factors. The voluntary or “opt in” strategy, where the institution has the vaccine, but it is up to the health worker to request vaccination, can raise uptake, but may have varying results at different healthcare levels [48]. Introduction of policies that mandate or encourage HBV vaccination in the workplace can result in a higher vaccination coverage [60].
The Sub-Saharan region has the highest Hepatitis B virus (HBV) rates, and health workers are at an increased risk of contracting nosocomial HBV infection. Vaccination of health workers plays a critical role in protecting them from sequelae of HBV; however, health-worker vaccination remains a challenge for many countries. This study was conducted to review practices/measures and challenges in the Sub-Saharan region relating to vaccination of health workers against HBV. We performed a literature review of articles addressing any aspect of HBV vaccination of health workers in the Sub-Saharan region sourced from PubMed, Embase, and Web of Science, including a case study of Malawi policies and strategies in training institutions and facilities. Our findings indicated that HBV awareness and vaccination were relatively high, but vaccination rates were lower, with 4.6–64.4% of those “ever vaccinated” completing the vaccination regimen. There was also great variation in the proportion of health workers exhibiting natural immunity from previous exposure (positive for anti-Hepatitis B core antibodies; 41–92%). Commonly cited reasons for non-uptake of vaccine included cost, lack of awareness of vaccine availability, and inadequate information concerning the vaccine. Countries in this region will require locally relevant data to develop cost-effective strategies that maximize the benefit to their health workers due to the great diversity of HBV epidemiology in the region.
Assessment of knowledge, attitudes and practice regarding hepatitis B infection among health care workers
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Susceptibility of healthcare workers in Kenya to hepatitis B: new strategies for facilitating vaccination uptake

Summary

Section snippets

Background

Site

Results

Discussion

Acknowledgements

J Hosp Infect

Am J Infect Control

Hepatitis B

Incidence and risk factors for acute hepatitis B in the United States, 1982–1998: implications for vaccination programs

J Infect Dis

Update on diagnosis, management, and prevention of hepatitis B virus infection

Clin Microbiol Rev

Introduction of hepatitis B vaccine into childhood immunization services

New immunization initiatives and progress toward the global control of hepatitis B

Curr Opin Infect Dis

Risks to health care workers in developing countries

N Engl J Med

Needle-stick injuries in an Ugandan teaching hospital

Ann Trop Med Parasitol

Risk and management of blood-borne infections in health care workers