Mitigating Vaccine Hesitancy and Building Trust to Prevent Future Measles Outbreaks in England.

Measles, a highly infectious respiratory viral infection associated with severe morbidity and mortality, is preventable when coverage with the highly effective measles, mumps and rubella vaccine (MMR) is ≥95%. Vaccine hesitancy is responsible for measles outbreaks in countries where measles had previously been eliminated, including in England, and is one of the ten threats to global public health identified by the World Health Organization (WHO). Official administrative 2012-2021 data on measles incidence and MMR coverage in England were reviewed alongside a scoping literature review on factors associated with MMR uptake in England. Whilst measles incidence has reduced significantly since 2012, sporadic measles outbreaks in England have occurred with geographic disparities and variations in MMR coverage. Over the last decade, MMR uptake has fallen across all regions with no area currently reaching the WHO target of 95% coverage of both doses of MMR necessary for herd immunity. Factors associated with MMR coverage overlap with the 3C (convenience, complacency and confidence) model of vaccine hesitancy. The COVID-19 pandemic has reinforced pre-existing vaccine hesitancy. Increasing MMR uptake by reducing vaccine hesitancy requires allocated funding for area-based and targeted domiciliary and community-specific immunisation services and interventions, public health catch-up campaigns and web-based decision aid tools.

Low influenza vaccine uptake by healthcare workers caring for the elderly in South African old age homes and primary healthcare facilities.

BACKGROUND: The elderly bear the highest burden of South Africa's estimated annual > 10 million influenza cases and > 11,000 influenza-related deaths. Unvaccinated healthcare workers (HCWs) are at high occupational risk of contracting influenza, and may transmit influenza to elderly patients in their care. Thus, the South African National Department of Health recommends that HCWs receive annual influenza vaccination. This study aimed to determine influenza vaccination coverage among HCWs; identify reasons for their vaccination status; and investigate if HCWs recommend vaccination to their elderly patients. METHODS: A descriptive study was conducted in 18 community health centres and 44 private sector and non-governmental organisation managed old age homes across South Africa, using a self-administered structured questionnaire, which was distributed to 360 HCWs present on the day of data collection. Data were captured using Microsoft Excel® and imported to Epi Info™ 7 (Centers for Disease Control and Prevention, USA) for descriptive statistical analysis. Ethics approval (SMUREC/P/36/2018: PG) and permission to conduct the study at the facilities were obtained. All participants provided informed consent. RESULTS: The response rate was 76.7% (276/360). Most participants were female (90.9% [251/276]), nursing professionals (81.2% [224/276]) with a mean age of 41.1 ± 11.7 years. Although 62.7% of participants indicated having ever received at least one dose of the influenza vaccine, influenza vaccine uptake for 2017 and 2018 was 24.36% (41/276) and 33.3% (92/276) respectively. The main reasons given for never being vaccinated against influenza were related to the unavailability of the vaccine (70.9%) and vaccine hesitancy (27.2%). Most participants (67.8% [187/276]) recommended vaccines to elderly patients in their care. CONCLUSION: The main reasons behind low influenza vaccine uptake by HCWs in South Africa who care for the elderly were related to unavailability of the vaccine and vaccine hesitancy. Strategies to educate HCWs on the importance of influenza vaccination, while concurrently increasing sustained and easy access to the vaccine by HCWs are needed to preserve public health.

Vaccine Hesitancy Drives Low Human Papillomavirus Vaccination Coverage in Girls Attending Public Schools in South Africa.

Girls aged ≥9 years attending South African public sector schools are provided with free human papillomavirus (HPV) vaccination, through a schools-based programme. HPV vaccine misinformation spread via social media in 2014, was identified as a barrier to obtaining parental informed consent in some districts, including Sedibeng District, which subsequently had the lowest HPV vaccination coverage in Gauteng Province in 2018. This study investigated vaccine hesitancy in caregivers of girls in Grade 4 to 7 aged ≥9 years attending public schools in Sedibeng District. A cross-sectional survey using a self-administered questionnaire was conducted among caregivers of age-eligible girls attending all public schools in Sedibeng District with first dose HPV vaccination coverage of <70%. The questionnaire included demographics; HPV vaccination status of girls; reasons for not being vaccinated; and a 5-item tool measuring the determinants of vaccine hesitancy (5C scale), using a 7-point Likert scale. Data were coded and captured on Microsoft Excel®. Except for collective responsibility which was reverse scored, the other 5C items (confidence, complacency, constraints, and calculation) were captured as follows: 1 = strongly disagree, 2 = moderately disagree, 3 = slightly disagree, 4 = neutral, 5 = slightly agree, 6 = moderately agree and 7 = strongly agree. Descriptive and inferential statistical analyses were conducted using Epi InfoTM. Of the principals of all schools with <70% HPV vaccination coverage, 69.6% (32/46) gave permission. The response rate from caregivers of girls present on the day of data collection was 36.8% (1,782/4,838), with 67.1% (1,196/1,782) of respondents reporting that their daughters had received ≥1 dose of HPV vaccine. Only 63.1% (370/586) of respondents with unvaccinated daughters answered the question on reasons, with 49.2% (182/370) reporting reasons related to vaccine hesitancy. Statistically significant differences between caregivers of vaccinated and unvaccinated daughters were identified for four of the five determinants of vaccine hesitancy: confidence (vaccinated group higher), complacency (unvaccinated group higher), constraints (unvaccinated group higher) and collective responsibility (vaccinated group higher). This is the first South African study to (a) report results of the 5C scale, which was found to be very useful for predicting vaccination uptake; and (b) confirm that the relatively low HPV vaccination coverage in Sedibeng District is largely driven by reasons related to vaccine hesitancy.

Human Papillomavirus Vaccine Hesitancy Highly Evident among Caregivers of Girls Attending South African Private Schools.

The viral spread of social media misinformation and disinformation regarding human papillomavirus (HPV) vaccination safety has resulted in widespread vaccine hesitancy and suboptimal HPV vaccination uptake. We previously reported that only 19.4% of age-eligible private school girls in South Africa in 2018 had received ≥1 HPV vaccine dose. Here, we report on reasons given by caregivers for why their daughters were unvaccinated. An online survey targeting caregivers of girls in grades 4-7 attending South African private schools was conducted. Caregivers of unvaccinated girls provided the most important reason for their daughter not being vaccinated by either selecting from a list of coded reasons or providing a free text reason. Free text reasons were analysed, coded and added to the list of coded reasons, which were categorised according to broad themes. Frequency distributions of reasons and categories were calculated. Most reasons were related to vaccine hesitancy (61.4%), followed by lack of access to the vaccine (21.3%) and lack of information (15.7%). HPV vaccination coverage among age-eligible girls can be improved by including private-sector schools in the South African HPV vaccination programme, training healthcare providers to advocate for HPV vaccination and extending HPV vaccination advocacy campaigns to include private-sector educators.

Predictors of parents' infant vaccination decisions: A concept derivation.

The myths surrounding coronavirus disease 2019 (COVID-19) vaccines have prompted scientists to refocus their attention on vaccine hesitancy, which is fuelled by the spread of misinformation. The scientific investigation of behavioural concepts relating to vaccine hesitancy can be enhanced by the examination of behavioural concepts from the field of consumer sciences. South African consumer scientists study personal decisions that contribute to individuals' well-being, including the decisions to prevent ill health. Current data on the predictors of vaccination decisions do not incorporate consumer science constructs imperative in decision-making, which could provide fresh insights in addressing vaccine hesitancy. This study aimed to investigate and illustrate the analogy between concepts of the Health Belief Model (HBM) as parent model, and consumer behaviour that could affect parents' infant vaccination decisions, by applying a concept derivation approach. The HBM was analysed within the context of public health, including literature from consumers' vaccination decisions, medical decisions, paediatrics, vaccinology, virology and nursing. Through a qualitative, theory derivation strategy, six main concepts of the HBM were redefined to consumer sciences, using four iterative concept derivation steps. Concept derivation resulted in consumer behaviour concepts that could be possible predictors of parents' infant vaccination decisions, including consumers' values; risk perception; consideration of immediate and future consequences; self-efficacy; cues to action; demographics; personal information and knowledge. These predictors could be a starting point for a context- and product-specific consumer primary preventive healthcare decisions model. Our findings highlight the opportunities for interdisciplinary collaboration in investigating consumer primary healthcare-related behaviour. CONTRIBUTION: This study introduced interfaces between consumer science and health science literature. Through interdisciplinary collaboration, a better understanding of influences to promote primary preventive healthcare can be achieved.

Promoting Healthy Ageing in South Africa Through Vaccination of the Elderly.

The World Health Organization estimates that globally, the proportion of people aged ≥60 years will more than double by the year 2050, with the majority of elderly people living in low- and middle-income countries such as South Africa. Population ageing is an impending public health concern, potentially negatively impacting on South Africa's economy and health system if the government does not adequately prepare for this change. Globally, many potential solutions to ensure healthy ageing are being discussed and implemented, including adopting a "life-course" approach to vaccination which includes vaccination of the elderly, since they are at considerable risk of severe morbidity and mortality from vaccine-preventable diseases. While vaccines are considered as one of the greatest tools for preventing childhood infectious disease morbidity and mortality, they are under-utilised in strategies for promoting healthy ageing in South Africa, where only influenza vaccination is available free of charge to the elderly accessing public sector healthcare. Population ageing coupled with the high incidence of vaccine-preventable diseases amongst elderly South Africans, necessitates establishing a comprehensive national policy and guidelines for vaccination of the elderly.

Misinformation Drives Low Human Papillomavirus Vaccination Coverage in South African Girls Attending Private Schools.

Background: Cervical cancer, caused by persistent human papillomavirus (HPV) infection, is the leading cause of female cancer deaths in South Africa. In 2014, the South African National Department of Health introduced a free public sector school-based HPV vaccination programme, targeting grade 4 girls aged ≥9 years. However, private sector school girls receive HPV vaccination through their healthcare providers at cost. This study investigated HPV vaccination knowledge, attitudes and practices of caregivers of girls aged ≥9 years in grades 4-7 attending South African private schools. Methods: A link to an online survey was circulated to caregivers via an email sent to school principals of all private schools in four provinces enrolling girls in grades 4-7. Following a poor post-reminder response, a paid Facebook survey-linked advert targeting South African Facebook users aged ≥25 years nationally was run for 4 days, and placed on the South African Vaccination and Immunisation Centre's Facebook page for 20 days. Results: Of 615 respondents, 413 provided HPV vaccination data and 455 completed the knowledge and attitudes tests. Most (76.5%) caregivers had good knowledge and 45.3% had positive attitudes. Of their daughters, 19.4% had received ≥1 dose of HPV vaccine. Of caregivers of unvaccinated girls, 44.3% and 41.1%, respectively were willing to vaccinate their daughters if vaccination was offered free and at their school. Caregivers of unvaccinated girls were more likely [odds ratio (OR): 3.8] to have been influenced by "other" influences (mainly online articles and anecdotal vaccine injury reports). Of caregivers influenced by their healthcare providers, caregivers of unvaccinated girls were more likely (OR: 0.2) to be influenced by alternative medical practitioners. Caregivers of vaccinated girls were more likely to have good knowledge (OR: 3.6) and positive attitudes (OR: 5.2). Having good knowledge strongly predicted (OR: 2.8) positive attitudes. Having negative attitudes strongly predicted (OR: 0.2) girls being unvaccinated. Conclusion: Providing free school-based HPV vaccination in the private sector may not increase HPV vaccination coverage to an optimal level. Since misinformation was the main driver of negative attitudes resulting in <20% of girls being vaccinated, an advocacy campaign targeting all stakeholders is urgently needed.

Contextualised strategies to increase childhood and adolescent vaccination coverage in South Africa: a mixed-methods study.

INTRODUCTION: Despite the unparalleled success of immunisation in the control of vaccine preventable diseases, immunisation coverage in South Africa remains suboptimal. While many evidence-based interventions have successfully improved vaccination coverage in other countries, they are not necessarily appropriate to the immunisation needs, barriers and facilitators of South Africa. The aim of this research is to investigate barriers and facilitators to optimal vaccination uptake, and develop contextualised strategies and implementation plans to increase childhood and adolescent vaccination coverage in South Africa. METHODS: The study will employ a mixed-methods research design. It will be conducted over three iterative phases and use the Adopt, Contextualise or Adapt (ACA) model as an overarching conceptual framework. Phase 1 will identify, and develop a sampling frame of, immunisation stakeholders involved in the design, planning and implementation of childhood and human papillomavirus immunisation programmes in South Africa. Phase 2 will identify the main barriers and facilitators to, and solutions for, increasing vaccination coverage. This phase will comprise exploratory qualitative research with stakeholders and a review of existing systematic reviews on interventions for improving vaccination coverage. Using the findings from Phase 2 and the ACA model, Phase 3 will develop a set of proposed interventions and implementation action plans for improving immunisation coverage in South Africa. These plans will be discussed, revised and finalised through a series of participatory stakeholder workshops and an online questionnaire, conducted as part of Phase 3. ETHICS: Ethical approval was obtained from the South African Medical Research Council (EC018-11/2018). No risks to participants are expected. Various steps will be taken to ensure the anonymity and confidentiality of participants. DISSEMINATION: The study findings will be shared at stakeholder workshops, the website of Cochrane South Africa and academic publications and conferences.

Impact of Lamivudine-Based Antiretroviral Treatment on Hepatitis B Viremia in HIV-Coinfected South Africans.

This prospective study investigated the impact of lamivudine-containing antiretroviral therapy (ART) on HIV-positive patients in South Africa with baseline hepatitis B virus (HBV) infection. Follow-up samples from 56 HBV/HIV co-infected patients, 25 with occult HBV infection (OBI) and 31 with chronic HBV infection (CHB), were available for analysis. HBV viral loads were quantified at 6, 12, 18, and 24 months post-ART initiation by the COBAS TaqMan HBV Test 48 assay, and the HBV polymerase gene was amplified with an in-house nested polymerase chain reaction assay. During 24 months of lamivudine-based ART, 6 of 8 (75%) OBI and 4 of 6 (67%) CHB patients achieved undetectable levels of HBV DNA, while 2 patients had persistent HBV DNA levels ≥ 2 × 105 despite lamivudine-based ART for 24 months. HIV viremia was undetectable in all patients at 12 months, suggesting high adherence to ART. Several lamivudine-associated HBV resistance mutations, including L180M, A181T, M204I, and M204V, were observed. Sequence analysis also revealed a rare genotype G infection. While resource-limited settings may use lamivudine-based ART because of availability and low cost, antivirals with dual therapy against HBV and HIV (e.g., lamivudine and tenofovir) should always be recommended with the regular monitoring of HBV viremia levels.

Impact of vaccine stock-outs on infant vaccination coverage: a hospital-based survey from South Africa.

Introduction: National population-based immunization coverage surveys provide data for validating official administrative coverage figures. However, these costly and logistically challenging surveys are conducted infrequently. This hospital-based records review determined coverage of birth-dose vaccines, fully immunized under 1-y-old coverage (FIC) of 12- to 59-mo-old children; and the reasons for missed vaccinations. Methods: Rotavirus surveillance in South Africa is based on under-5-y-old children being treated for diarrhoea, and includes photocopying the official vaccination document and collecting data on reasons for missed vaccinations. These data were captured from all 508 records collected from 2011 to 2014, and subjected to descriptive statistical analysis. Results: Bacille Calmette Guérin coverage was 99%; oral polio vaccine birth dose (OPV(0)) coverage was 99%. Coverage for 12- to 59-mo-olds ranged from 75% for the pneumococcal conjugate vaccine third dose to 99% for OPV(0). Several instances of subsequent doses being recorded without prior doses being received resulted in a FIC of 55%. In total, 207 vaccinations were missed by 88 children. Vaccine stock-outs were responsible for 62% of missed vaccinations. Conclusions: Efforts to improve vaccine stock management at facility and district levels should be implemented, and should include vaccinator training and supervision to eliminate vaccine stock-outs and missed vaccination opportunities.

Molecular characterization of hepatitis B virus X gene in HIV-positive South Africans.

Hepatitis B virus (HBV) infection is a major public health problem worldwide and the major cause of hepatocellular carcinoma (HCC) in South Africa. The role of HBV in HCC is not well understood, although the HBV X gene has been implicated as a critical factor. Data on the HBV X gene in HIV-positive South Africans are limited; thus, we investigated X gene variability in 24 HIV-infected treatment-naïve patients at Dr George Mukhari Academic Hospital. Quantitative and qualitative HBV DNA tests were conducted using real-time and in-house polymerase chain reaction (PCR) assays, respectively, targeting the complete HBV X gene. In-house PCR-positive samples were cloned using the P-Gem T-easy vector System II and sequenced. By phylogenetic analysis, X gene sequences were classified as subgenotype A1 (n = 15), A2 (n = 4), and D1 (n = 4), and one dual infection with subgenotypes as A1 and C. The basal core promoter mutations T1753C, A1762T, and G1764A were identified in the majority of sequences. Genotype D sequences had a 6-nucleotide insertion. In conclusion, subgenotype A1 was predominant, and a rare dual infection of HBV genotype A and C was detected. The 6-nucleotide insertion could represent a unique variant in the region and highlights the need for functional studies of HBV X gene variants, particularly from resource-limited settings.

Improving skills and institutional capacity to strengthen adolescent immunisation programmes and health systems in African countries through HPV vaccine introduction.

Several African countries have recently introduced or are currently introducing the HPV vaccine, either nationwide or through demonstration projects, while some countries are planning for introduction. A collaborative project was developed to strengthen country adolescent immunisation programmes and health systems in the African Region, addressing unique public health considerations of HPV vaccination: adolescents as the primary target group, delivery platforms (e.g. school-based and facility based), socio-behavioural issues, and the opportunity to deliver other health interventions alongside HPV vaccination. Following a successful "taking-stock" meeting, a training programme was drafted to assist countries to strengthen the integration of adolescent health interventions using HPV vaccination as an entry point. Two workshops were conducted in the Eastern and Southern African Regions. All countries reported on progress made during a final joint symposium. Of the 20 countries invited to participate in either of the workshops and/or final symposium, 17 countries participated: Angola, Botswana, Ethiopia, Kenya, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Countries that are currently implementing HPV vaccination programmes, either nationally or through demonstration projects, reported varying degrees of integration with other adolescent health interventions. The most commonly reported adolescent health interventions alongside HPV vaccination include health education (including sexually transmitted infections), deworming and delivering of other vaccines like tetanus toxoid (TT) or tetanus diphtheria (Td). The project has successfully (a) established an African-based network that will advocate for incorporating the HPV vaccine into national immunisation programmes; (b) created a platform for experience exchange and thereby contributed to novel ideas of revitalising and strengthening school-based health programmes as delivery platform of adolescent immunisation services and other adolescent health interventions, as well as identifying ways of reaching out-of-school girls through facility and community based programmes; and (c) laid a foundation for incorporating future adolescent vaccination programmes.

High prevalence of active and occult hepatitis B virus infections in healthcare workers from two provinces of South Africa.

BACKGROUND: Hepatitis B (HB) is a vaccine-preventable liver disease caused by infection with the blood-borne hepatitis B virus (HBV). South African healthcare workers (HCWs) may be at high risk of occupational exposure to HBV infection, since previous studies have found suboptimal levels of protection against HBV in HCWs. METHODS: A descriptive prevalence study based on self-administered questionnaires with data on demographics and HB vaccination status, and stored serum samples collected from 2009 to 2012, from 333 HCWs working or studying in Gauteng and Mpumalanga province hospitals or nursing colleges, was conducted. Samples were tested for HB surface antigen (HBsAg), antibodies to HBsAg (anti-HBs), antibodies to HB core antigen (anti-HBc), and HBV deoxyribonucleic acid (DNA). RESULTS: The majority of HCWs from whom the serum samples were drawn were black (91.4% [298/326]), female (82.6% [275/333]) and had received at least one dose of HB vaccine (70.9% [236/333]). The average age was 38.8years (range: 19-62). Of the HCWs, 23.2% (73/314) were susceptible (negative for all markers); 9.6% (30/314) were infected (HBsAg and/or DNA positive); 29.0% (91/314) were exposed (positive for either HBsAg, anti-HBc, or DNA); 18.8% (59/314) were immune due to natural infection (anti-HBs and anti-HBc positive only); while 47.8% (150/314) were immune due to vaccination (anti-HBs positive only). Furthermore, HBV DNA was detected in 8.6% (27/314) and occult HBV infection (OBI) (HBV DNA positive but HBsAg negative) was found in 6.7% (21/314) of samples. DISCUSSION AND CONCLUSION: This study, which is the first to report OBI in South African HCWs, found high rates of active HBV infection and sub-optimal protection against HBV in HCWs. There is a need to strengthen vaccination programmes through a policy that ensures protection for all HCWs and their patients.

Complete genome analysis of hepatitis B virus in human immunodeficiency virus infected and uninfected South Africans.

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections are highly endemic in South Africa. Data on the complete genome sequences of HBV in HIV-positive patients in South Africa are scanty. This study characterized the complete HBV genome isolated from both HIV-positive and negative patients at the Dr George Mukhari Academic Hospital (DGMAH), Pretoria. Serum samples from nine (five HIV-positive and four HIV-negative) patients attending the DGMAH from 2007 to 2011 were serologically tested, amplified, and sequenced for complete genome. Phylogenetic tree was constructed using MEGA6.0. Mutations were analyzed by comparing the sequences with genotype-matched GenBank references. Eight patients were HBsAg positive, with only one from the HIV positive group being negative. Phylogenetic analysis of the complete genome sequences classified them into five genotypes; A1 (n = 4), A2 (n = 1), C1 (n = 2), D1 (n = 1), and D3 (n = 1). Deletions up to 35 nucleotides in length were identified in this study. No drug resistance mutations were identified in the P ORF, while the L217R mutation was identified in one subgenotype A2 sequence. The double (A1762T/G1764A) and triple (T1753C/A1762T/G1764A) mutations in the Basal core promoter were identified in four and two sequences, respectively. In the core region, mutation G1888A was identified in four of the subgenotype A1 sequences. In conclusion, this study has added to the limited South African data on HBV genotypes and mutations in HBV/HIV co-infected and HBV mono-infected patients, based on complete HBV genome analysis. Subgenotype A1 was predominant, and no drug-resistant mutants were detected in the study. J. Med. Virol. 88:1560-1566, 2016. © 2016 Wiley Periodicals, Inc.

Hepatitis B virus reactivation or reinfection in a FEM-PrEP participant: a case report.

INTRODUCTION: The FEM-PrEP trial was a pre-exposure prophylaxis clinical trial to test the safety and efficacy of Truvada (tenofovir disoproxil fumarate and emtricitabine) in the prevention of human immunodeficiency virus infection. Because Truvada can suppress hepatitis B virus replication, and withdrawal of Truvada can cause hepatic flares in patients with chronic hepatitis B, pre-enrollment screening included serological screening for hepatitis B virus markers. Women with chronic infections were not enrolled in the trial. Women found to be unprotected against hepatitis B were enrolled and offered three doses of hepatitis B vaccine. Reinfection and reactivation of previously resolved hepatitis B virus infections have been documented in immunosuppressed individuals but not in healthy individuals. We present the case of a participant enrolled in the FEM-PrEP clinical trial with baseline evidence of immunity against hepatitis B virus who subsequently developed acute hepatitis B. CASE PRESENTATION: A 21-year-old Black non-pregnant woman was enrolled in the FEM-PrEP trial. She was human immunodeficiency virus-negative and a serological test for hepatitis B virus was negative. She had evidence of low levels of protection against hepatitis B virus and normal liver function. She had no hepatitis B vaccination history, thus it was concluded that she had post-infection immunity. At week 36 she presented with severely elevated liver enzyme levels that, upon further investigation, were a result of acute hepatitis B virus infection. The infection followed an asymptomatic course until full recovery of her liver enzymes a few weeks later. At study unblinding, the participant was found to be on the Truvada arm. Retrospective plasma drug level testing found low levels of study drugs from week 4. The participant remained human immunodeficiency virus-negative throughout the study. CONCLUSION: Hepatitis B virus infection reactivation or reinfection is a rare phenomenon in healthy individuals. However, reactivations have been reported in patients being treated for chronic hepatitis B with the drugs contained in Truvada, after treatment had been withdrawn. This participant may have reactivated after stopping Truvada, or she may have reactivated spontaneously owing to relatively low levels of protective antibodies against hepatitis B. Alternatively, she may have been reinfected. Clinicians should be aware that hepatitis B virus reactivation or reinfection may cause elevated transaminases even in the presence of low baseline immunity.

Hepatitis B vaccination of healthcare workers at the Princess Marina Hospital, Botswana.

BACKGROUND: Batswana (i.e., the people of Botswana) healthcare workers (HCWs) are at high risk for occupational exposure to hepatitis B virus (HBV), thus the Botswana Ministry of Health recommends that HCWs should receive three doses of hepatitis B (HB) vaccine. However, there are no data on HB vaccination uptake by Batswana HCWs. This study investigated knowledge of, and attitudes towards, HB prevention and control, and predictors of HB vaccination uptake in HCWs at the Princess Marina Hospital during 2010. METHODS: Self-administered questionnaires were distributed to doctors, nurses and laboratory workers (n=200). Knowledge was measured using 14 questions; attitude was measured using a 5-point Likert scale and 9 statements. Data on vaccination status and demographics were collected. RESULTS: Of the respondents, 17.2% (20/116) had good knowledge and 97.4% (113/116) had positive attitudes. At least one dose of HB vaccine had been received by 50.9% (59/116), while 31.0% (36/116) had received all three doses. Profession was the only predictor of HB vaccination uptake, with being a laboratory worker (OR=61.0) or a doctor (OR=51.5) predicting HB vaccination uptake with at least one dose. CONCLUSION: This is the first study on HB vaccination of Batswana HCWs, and shows that HB vaccination uptake is suboptimal.

Evidence for a change in the epidemiology of hepatitis B virus infection after nearly two decades of universal hepatitis B vaccination in South Africa.

The hepatitis B vaccine has been part of the South African Expanded Program on Immunization since April 1995 but its long-term impact remains unknown. This study tested 1,206 sera collected from patients aged 1-25 years from various health facilities across the country for HBV serological markers and HBV DNA. Based on the year the vaccine was introduced, samples were stratified by age into pre- and post-vaccine introduction populations, which were then compared for evidence of immunity and chronic carriage using the Chi-square test. Where HIV status was known, subset analyses were performed. Immunity to HBV infection increased from 13.0% in the pre- to 57.0% in the post-vaccine introduction population (P < 0.001). This decreased with increasing age within the post-vaccine introduction population (76.1% for 1-5 years, 50.0% for 6-10 years, and 46.3% for 11-16 years). In addition, HBV chronic carriage was significantly (P = 0.003) reduced in the post- (1.4%) compared to the pre-vaccine introduction population (4.2%). The difference in prevalence of active HBV infection in the serologically exposed pre- and post-vaccine introduction populations was not statistically significant. Subset analyses showed that evidence of immunity was significantly (P < 0.001) higher in the HIV negative compared to the HIV positive subset in both populations. Universal hepatitis B vaccination has been a remarkable success, with a significant increase in immunity to HBV infection. The observation that HBV chronic carriage increases as immunity wanes over time calls into question whether the time has come to consider a pre-adolescence vaccine booster dose policy.

National guidelines not always followed when diagnosing smear-negative pulmonary tuberculosis in patients with HIV in Botswana.

BACKGROUND: Diagnosis of smear negative pulmonary tuberculosis (SNPTB) is challenging, especially in patients with HIV. The Botswana National Tuberculosis Program (BNTP) guidelines give guidance in diagnosing and treating SNPTB. Patients with chronic cough should be screened for TB by 3 sputum smear investigations. If negative, a chest x-ray (CXR) should be performed. If negative for TB, antimicrobial treatment for other infections should be started. We investigated the clinicians' use of the guidelines in clinical practice. METHODS: Data regarding the medical history (coughing period), requested and conducted investigations concerning tuberculosis diagnosis (sputum smear or culture or CXR) or alternative diagnoses (sputum microscopy or blood or sputum culture for diagnosis of other organisms), in SNPTB HIV-positive patients (outpatients and admitted patients) from 2006-2009 in a district hospital in Botswana were extracted from all available hospital medical records. Additionally, a survey was done in all doctors diagnosing SNPTB in this hospital using a self-administered questionnaire with questions regarding the application of the BNTP guidelines in practice. Descriptive analyses of collected data were performed to test the compliance to the guidelines. RESULTS: Data from medical records showed that in 47.0% (132/281) of patients, TB treatment was started without microbiological results from sputum smears. Other methods to rule out or confirm PTB were used in 2.1% (6/281); and 99.6% (280/281) of SNPTB patients had received a CXR. The survey in 7 clinicians found that all always used CXR, and all clinicians requested three sputum results only sometimes. Six out of 7 clinicians started antibiotics before starting TB treatment. Reasons clinicians gave for difficulties in following the guidelines included inability of patients to produce sputum; and laboratory delays in releasing sputum results. CONCLUSION: Between 2006 and 2009 a high proportion of SNPTB diagnoses in a district hospital in Botswana were not supported by laboratory investigation.

An update after 16 years of hepatitis B vaccination in South Africa.

Hepatitis B (HB) virus (HBV) infection is highly endemic with at least 65 million chronic HB surface antigen (HBsAg) carriers in Africa, 25% of whom are expected to die from liver disease. Before the introduction of the HB vaccine, the prevalence of chronic carriage of HBV in black South Africans was 9.6%, with 76% having been previously exposed to HBV. The major transmission route in South Africa is unexplained horizontal transmission between toddlers, with most transmission occurring before the age of 5 years. During adolescence and early adulthood, sexual transmission becomes the dominant route, while healthcare workers (HCWs) are also at risk for parenteral/percutaneous transmission during occupational exposures. In 1995 the South African Department of Health (SADoH) incorporated the HB vaccine, administered as a monovalent, into the Expanded Programme on Immunisation (EPI) at 6, 10, and 14 weeks of age, and studies conducted thereafter have found it to be safe and highly effective. Catch-up vaccination for adolescents was not introduced and there is no schools-based vaccination programme. The SADoH recommends HB vaccination of HCWs, but this is not mandatory and there is no national policy, thus HB vaccination uptake in HCWs is sub-optimal. Since 1995, studies on children have found that the prevalence of chronic HBsAg carriage has decreased, as has the incidence of paediatric hepatocellular carcinoma and HBV-related membranous nephropathy. The SADoH should focus their efforts on attaining a high infant HB vaccine coverage, prepare for introducing a HB birth dose, and consider using a hexavalent vaccine (DTaP-IPV-Hib-HepB). The department may also want to consider including targeted HB vaccination for 12 year-olds, if their Road to Health Cards show they were not vaccinated as infants. A national policy is needed for HCWs to ensure that they are fully vaccinated and protected against HBV infection.

Meeting the need for advocacy, social mobilisation and communication in the introduction of three new vaccines in South Africa - successes and challenges.

Advocacy, social mobilisation and communication are key components of the successful introduction of new vaccines into childhood immunisation schedules. The development of many new vaccines and the innovation of finance mechanisms, means more efficacious vaccines are becoming available to children in developing countries. At the same time, communication technology is developing at a rapid rate, and with the dramatic decrease in vaccine-preventable diseases over the past few decades, the public have become increasingly exposed to confusing and conflicting information about the need for vaccination. The science of vaccines has become more complex, making effective, clear and consistent communication for healthcare workers and caregivers critical to the uptake of and adherence to life-saving vaccination. The introduction of two new vaccines, the 7-valent pneumococcal conjugate vaccine and the rotavirus vaccine together with the new pentavalent vaccine, which includes inactivated polio vaccine and replaced the former combination vaccine with four antigens, into the South African Expanded Programme on Immunisation over a short period of time, has been met with a number of challenges, some of which led to a lowering of confidence in the Department of Health to deliver on its promises. Had consistent advocacy, social mobilisation and communication efforts not been in place, efforts to make an impact on the burden of disease may not have been as successful. This paper focuses on the lessons learned about effective advocacy with decision makers, social mobilisation, communication with parents and caregivers, and training healthcare workers regarding the introduction of the new vaccines.