Vaccine 37 (2019) 6894–6899 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Maternal reasons for non-receipt of valid Hepatitis B birth dose among mother-infant pairs attending routine immunization clinics, South-east, Nigeria ⇑ Uchechukwu Joel Okenwa a,b, , Magbagbeola David Dairo b, Belinda Uba a,c, Olufemi Ajumobi a,c a Nigeria Field Epidemiology and Laboratory Training Program, Abuja, Nigeria b Department of Epidemiology and Medical Statistics, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria c African Field Epidemiology Network, Nigeria Country Office, Abuja, Nigeria article info abstract Article history: Background: Hepatitis B vaccine (HepB) is an effective tool in prevention of hepatitis B virus (HBV) infec- Received 23 April 2019 tion. When administered at birth, it prevents mother-to-child transmission of acute and chronic HBV Received in revised form 16 September infection. However, despite a decade and half of implementation of HepB birth dose (HepB-BD), uptake 2019 has remained persistently low in Enugu State, Nigeria. We assessed the uptake of valid HepB-BD and the Accepted 17 September 2019 reasons given by mothers of infants for not receiving the HepB-BD in Enugu State, South-east Nigeria. Available online 24 September 2019 Methods: An hospital-based cross-sectional survey was conducted among mother-infant pairs attending immunization clinics at randomly selected health facilities in Enugu State, Nigeria. Overall, 344 mothers Keywords: and their infant children in this study were interviewed using structured questionnaire. Data on maternal Hepatitis B valid-birth-dose Immunization reasons for non-receipt of valid HepB-BD by their infants and their recommendations on ways to improve Maternal valid HepB-BD uptake, were collected. We defined valid birth dose as the receipt of first dose of HepB Nigeria within 24 h of birth. Results: Overall, 254 (73.8%) infants did not receive valid HepB-BD. Major reasons for its non-receipt were vaccine not available at place of delivery (91.3%, n = 232), delivery did not take place on immuniza- tion day (75.6%, n = 192), lack of awareness on timing of valid HepB-BD (72.8%, n = 185), long distance from the health facility (5.1%, n = 13) and fee payment for immunization (6.3%, n = 16). Of the 384 mater- nal recommendations, 143 (37.2%) emphasized female literacy while 87 (22.7%) indicated pre- positioning the vaccines at labor rooms to improve valid HepB-BD uptake. Conclusion: The low receipt of valid HepB-BD among infants attending routine immunization clinics, found in this study were attributed to lack of maternal awareness on timing of HepB-BD and poor inte- gration of child delivery and immunization services. We recommend educating mothers on benefits of a timely HepB-BD and pre-positioning the vaccines at the labor rooms. Ó 2019 Elsevier Ltd. All rights reserved. 1. Background with high prevalence of HBV infection such as Nigeria has mother- to-child-transmission (MTCT) as the major route of transmission. Hepatitis B virus (HBV) infection is a highly infectious and Notably, 90% of the HBV-infected infants are at increased risk of potentially life-threatening disease, 50–100 times more infectious developing chronic HBV [6–8]. than HIV and can cause both acute and chronic disease [1,2]. HepB vaccination at birth reduces the incidence of the HBV According to the World Health Organization (WHO), one-third of infection through prevention of MTCT. However, the efficacy of the global population have been infected with the HBV worldwide the vaccine in preventing perinatal transmission declines with and about 4–6% of the world population are chronic carriers [3].In increasing interval between birth and the administration of the 2017, WHO Western Pacific and African regions, each with esti- vaccine [9]. This underscores the need for timely vaccination of mated prevalence of 6%; jointly accounted for 68% of the global infants with the HepB birth dose (HepB-BD). Accordingly, WHO burden [4]. Nigeria has a pooled prevalence estimate of 13.6% recommended that ‘‘all infants should receive their first dose of and thus is classified as hyper-endemic for HBV infection [5]. Areas HepB vaccine as soon as possible after birth, preferably within 24 h” [6], irrespective of endemicity of HBV infection in countries, ⇑ Corresponding author. i.e. valid HepB-BD. HepB at birth is a monovalent dose which is fol- E-mail address: [email protected] (U.J. Okenwa). lowed by additional two or three doses depending on the country’s https://doi.org/10.1016/j.vaccine.2019.09.056 0264-410X/Ó 2019 Elsevier Ltd. All rights reserved. U.J. Okenwa et al. / Vaccine 37 (2019) 6894–6899 6895 immunization schedule. In Nigeria, the birth dose is followed by Stage 3: We selected one health facility offering routine immuniza- additional three doses with a minimum interval of four weeks tion using a simple random sampling by balloting from each of the which are given in combination with Diphtheria Pertussis and 18 wards based on the list of health facilities (HFs) obtained from Tetanus vaccine and Haemophilus influenza type B vaccine as pen- the LIO. Finally, in the fourth stage, mother-infant pairs were tavalent vaccine. National Primary Health Care Development selected using systematic sampling technique, See Fig. 1. Agency (NPHCDA), an agency responsible for implementation of primary health care in Nigeria, recommended that all infants 2.3.1. Selection of mother-infant pairs should receive their first dose of HB vaccine as soon as possible The average monthly number of mother-infant pairs and the (less than 24 h) after birth and up to 2 weeks [10]. However, the immunization sessions in a month in each of the selected health timeliness of HepB-BD vaccination remains neglected. facilities were collected from the LIOs. The average number of each Despite a decade and half implementation of HepB-BD in Nige- of the selected HFs were summed up to obtain the sample frame of ria, uptake has remained persistently low in Enugu State, with a 1039. Using probability proportional by size, the proportion of probable high risk of mother-to-child-transmission of HB in fetuses mother-infant pairs per HF (n) was obtained. We divided the aver- and chronic HBV in newborns and eventual death [7]. The 2017 age number per HF by the sample frame and then multiplied by the Nigeria National Immunization Coverage Survey revealed that sample size (N). Thereafter, the sampling interval was calculated 31% of the infants received valid HepB-BD in Enugu State [11].In by dividing the ‘N’ by ‘n’, (N/n) and selected the first mother- order to avert the inherent risk of mother-to-child-transmission infant pair by simple random sampling by balloting. Subsequently, of HBV, we assessed the uptake of valid HepB-BD and the maternal every nth mother-infant pair was selected by systematic sampling reasons for its non-receipt among infants attending immunization at each immunization session of the selected HFs until the sample clinics in Enugu State, South-east Nigeria. size for that HF was completed. The number of mother-infant pairs recruited in an immunization session was calculated by dividing 2. Methods the number allocated in a month by the number of sessions for each of the HFs (Table 1). 2.1. Study area 2.4. Data collection This study was conducted between October 2017 and January 2018 at the health facilities offering immunization services in The questionnaire was pretested among 18 mother-infant pairs Enugu State, Nigeria. The state has 291 wards in its 17 local gov- in two health facilities not selected for the study and checked for ernment areas (LGA) with five largely urban, while 12 are rural. comprehension, reliability, validity and necessary modifications These LGAs are distributed across three senatorial zones, namely; made. Trained research assistants administered pretested struc- Enugu-East (6 LGAs), Enugu-West (5 LGAs) and Enugu-North (6 tured questionnaire to collect information on the mother’s socio- LGAs). There are 912 health facilities, of which overall 602 (public, demographic characteristics, their reasons for non-vaccination of mission and private hospitals) offer routine immunization services. their infants and recommendations on ways to improve valid The number of immunization sessions per month per health facil- HepB-BD uptake. Additionally, information on infants’ date of birth ity varies from daily to monthly based on the target population of and time of HepB-BD vaccination was collected. These were con- their catchment areas. The immunization services entail giving firmed in the infants’ immunization card and hospital immuniza- every newborn an immunization card where National program tion register where available and applicable. on immunization (NPI) vaccinations and dates of administration of the vaccines are recorded by immunization staff. The immuniza- 2.5. Data processing and analysis tion cards also contain information such as birth record, vaccina- tion schedules, growth monitoring charts as well as the address Data entry, cleaning and analysis was conducted using Epi-info of parents. version 7.2 and Microsoft Excel. Age of participants was presented in mean and standard deviation. Categorical variables including 2.2. Study population and design respondents with valid dose of HepB and the reasons for non- vaccination were presented in frequencies and proportions. Valid A hospital-based cross-sectional survey was conducted among Hepatitis B vaccine birth dose was defined as the receipt of first mother-infant pairs attending immunization clinics in Enugu State, dose of HBV within 24 h of birth. Nigeria. The mother-infant’ pairs were attendees of 18 health facil- ities selected from 18 different wards spanning six of the 17 LGAs 2.6. Ethical consideration of the state. The ethical approval for the study was obtained from the 2.3.