Keeping the Passion
Alive: Making the Right
Turn
Geraldine Padilla, PhD
Professor and Associate Dean
UCSF School of Nursing
Signs of Need for Change
• Decrease in research interest, creativity,
energy
• Interest in finding something new
• Hopping around from one scientific
area to another
• Feeling a knowledge deficit
Value of Change
• Renewed energy and sense of
discovery
• New challenges
– New collaborators
– Study in foreign land, culture, language
– New funding sources, regulations
NIH Support for Change
NRSA for Senior Fellows (F33):
NIH awards F33s to experienced
scientists who wish to make major
changes in the direction of their
research careers or who wish to
broaden their scientific background by
acquiring new research capabilities.
(Supported by NINR and many other Institutes)
NIH Support for Change
Career Enhancement Award (K18):
Provides full/part-time support for
experienced scientists who wish to
broaden their scientific capabilities or
to make changes in their research
careers by acquiring new research skills
or knowledge. Award usually no more
than 1-2 years. (Not supported by NINR and
others. Stem cell research supported by some Institutes)
Other Support for Change
Fulbright (Full Grant):
These grants provide some funding for
research, books, supplies, in country
travel, living allowance.
• Good and feasible study plan
• Strong host country support for the
project
Institutional Support for Change
• Sabbatical, Mentor, Training
• Research Intensive Universities: OK if
fundable and publishable
• Education intensive Universities: OK if
content/clinical expertise and teaching
continue in assigned areas
Personal Plan
• Used sabbatical
• Obtained in country support from the
Philippine Cancer Society
• Collaborated with the Calif Div and
Nat’l American Cancer Societies
• Obtained Fulbright Award for 4
months
Hepatitis B and Filipino Infants
PROBLEM: HBV Prevalence in Filipinos
• 1986 estimates: 12% of Filipinos (about 5
million) infected with HBV (Lingao et al. Am J Epi
1986;123:473-480)
• 2004 estimates: 8 – 10% of Filipinos
(about 8 million) infected with HBV
(Philippine Cancer Society, 2004)
• 2008 estimates to be published by PCS
Prevalence of Chronic Hepatitis B
High: 8% & above
Intermediate: 2-8%
Low: Below 2%
Hepatitis B and Filipino Infants
Purposes:
• Describe status of Philippine policy
implementation on HBV inoculation of
newborns
• Explore strategies to guide policy
implementation
• Work with the Philippine Cancer Society
on plans to promote implementation
HEPATITIS B DISEASE
• Inflammatory liver condition caused by
hepatitis B virus (HBV) infection
• Persons with HBV may recover and
develop lifelong immunity from the virus
or they may become chronically infected
HEPATITIS B DISEASE
Acute Hepatitis B
• duration: several weeks
• symptoms: poor appetite, weakness, nausea,
vomiting, abdominal or joint pain, jaundice, dark
urine, skin rashes
Chronic Hepatitis B
• duration: lifetime
• symptoms: 30% no signs of illness
• mortality: 15-25% die early of HBV-related
diseases, e.g. liver cancer, cirrhosis
WHO 2001, So 2005, WHO 2003
Hepatitis B and Filipino Infants
HBV: Chronic infection
• Mother to infant transmission accounts
for 1/3 of HBsAg positive infants at 1
year (Lingao et al., 1989)
• 15-25% of chronically infected die of
HBV-related diseases (WHO, 2003)
Philippine DOH
(Central) Manila
DOH CHDRegion V
(6 Provinces)
Provincial
Health
Office
City/Municipal
Health Office
District Health
Office
Barangay Health
Center
District / Provincial
Hospitals
US COMPREHENSIVE IMMUNIZATION STRATEGY
ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP)
Hepatitis B and Filipino Infants
HB Vaccination Schedule for Newborns: Philippine
DoH Policy (2006)
• First dose at birth*
• Second dose at 6 weeks**
• Third dose at 14 weeks**
*If mother HBsAg or HBeAg positive, 1st dose given
ASAP after birth + HB immune globulin if available
and/or affordable
**2nd, 3rd doses timed with other immunizations to
promote adherence to follow-ups
Hepatitis B and Filipino Infants
HB Vaccine as part of Expanded Program on
Immunization: Philippine DoH Policy (2006)
• PDoH supplies free HB vaccine for
children 0-11 mo. through public health
facilities nationwide
–2007 75% of HB vaccine needs
–2008 100% of HB vaccine needs
Hepatitis B and Filipino Infants
METHODOLOGY: Design & Subjects
• Pilot, descriptive study
• Face-to-face recorded interviews
• 32 stakeholders, but N=30 health care
providers
• > 21 years, Speak English/Tagalog
• Involved in implementing the HBV
infant vaccination program
Hepatitis B and Filipino Infants
HBV Immunization Study: Interview
Content
• Knowledge of HBV infant vaccination
policy
• Role in policy implementation
• Perceived barriers, facilitators, strategies
related to policy implementation
Hepatitis B and Filipino Infants
Procedures with participants
• Signed a consent form
• Participated in a 30 min - one hr interview
• Interviews audio recorded, transcribed, all
names erased, recordings destroyed after
transcription
• Interviewed in work place or a convenient
location
• Received P500 (pesos)
Hepatitis B and Filipino Infants
Health Care Providers
• 30 interviewed from 1/18-4/15/07, 1/09
• 21 females, 9 males
• 29 gov’t, 1 NGO
• 12 MDs, 15 RNs, 1 Midwife, 2 Barangay
Health Workers
• 14 Admin/EPI Coordin, 1 Med Train, 12
Clinicians, 2 BHWs, 1 NGO volunteer
l
Hepatitis B and Filipino Infants
HBV Immunization Study: 23 locations
• 15 urban, 4 semi-urban, 4 rural
• 13 metro Manila, 1 Marikina
• Provinces: 6 Sorsogon, 1 Ilocos Sur,
1 Masbate, 1 Batangas
Hepatitis B and Filipino Infants
HBV Immunization Study: Results
Impact of PDoH decentralization
• PDoH supplies the vaccine
• Local governments budget support of
public health clinics which implement HBV
immunization policy
• Financial support uneven across 23
locations
Hepatitis B and Filipino Infants
HBV Immunization Study: Results, 23 locations
Written policy
on hand
2 Rural
2 Semi-rural
6 Urban
No written policy
on hand
2 Rural
2 Semi-rural
7 Urban
2 NA
Hepatitis B and Filipino Infants
HBV Immunization Study: Results, 23 locations
Cold storage charts/records on hand
• 5 out of 7 clinics
• 2 out of 5 hospitals
• 5 out of 7 city/provincial health offices
• 1 Health office, 1 clinic, 1 NGO, 1 Business not applicable
Hepatitis B and Filipino Infants
HBV Immunization Study: Results, 23 locations
Vaccination charts/records available
• 5 out of 8 clinics
• 1 out of 5 hospitals
• 3 out of 7 health offices
• 1 Health office, 1 NGO, 1 Business - not
applicable
Hepatitis B & Filipino Infants: Results
21 applicable locations
Factors facilitating policy implementation - but
not consistently
• Monovalent HB vaccine 10-dose vials available
• Training programs for health care providers available
• HB immunization patient handouts and brochures
available at clinics and hospitals
• Health care locations promoted 2nd, 3rd dose followups with tracking through immunization cards &
designated personnel
Hepatitis B & Filipino Infants: Results
21 applicable locations
Barriers to policy implementation
• Problems with vaccine and syringe distribution
• Inadequate clinic budgets for appropriate personnel
• Lack of money and distances to clinic for follow-up
doses
• Issues with refrigeration capacity and cold storage
maintenance in emergency situations or for
transport in rural areas
Hepatitis B & Filipino Infants: Results
30 Health Care Providers
• Knowledge about vaccine integrity: All
30
• Knowledge about Hep B infant
inoculation policy: Knowledge deficit
among some health professionals
Hepatitis B & Filipino Infants: Results
30 Health Care Providers
Type of inoculation schedule
implemented
• 22 followed new schedule (birth, 6, 14
weeks)
• 4 followed old/other schedule (6, 10,
14 weeks, or other)
• 4 followed both
Hepatitis B & Filipino Infants: Results
30 Health Care Providers
Personal knowledge of vaccine
availability policy
• 27 knowledgeable
• 3 ignorant
Hepatitis B & Filipino Infants: Results
30 Health Care Providers
Knowledge & attitudes concerning
vaccine policy
• 29 reported no negative cultural biases
among mothers toward infant
immunizations
• but moderate to poor client knowledge
of the inoculation schedule or
appreciation of its importance
Hepatitis B and Filipino Infants
HBV Transmission Modes
Transmission occurs when infected blood
enters the body of a person not infected
• Infected mother to child at birth
• Wound to wound contact
• Sharing toothbrushes, razors
• Reusing needles (medical or nonmedical)
• Unprotected sex with infected person
Hepatitis B & Filipino Infants: Results
HBV Transmission Myths shared by
Filipinos
• Sharing food or water
• Sharing eating utensils, drinking water
• Casual contact
• Hugging or kissing
• Breast feeding
Hepatitis B & Filipino Infants:
Preliminary Conclusions
• Some progress made to reach 100% HBV
inoculation of newborns
• Exact information on number of newborns
receiving 1st, 2nd and 3rd doses unknown
• Insufficient data to determine rural versus
urban differences in policy knowledge or
implementation
Hepatitis B & Filipino Infants:
Research Needed
• Identify gaps in knowledge and
implementation of HBV vaccination policy
& procedures country-wide
• Identify strategies/technologies to promote
efficient distribution & storage of supplies
• Describe gap between births recorded and
inoculations received across Barangays, in
rural versus urban areas
Hepatitis B & Filipino Infants:
Research Needed
Improve knowledge of & adherence
to HBV infant inoculation policy
among health care providers
Identify strategies to assist mothers to
adhere to inoculation schedule
Hepatitis B & Filipino Infants:
Research Needed
Evaluate impact of Train-the-Trainer strategy
implemented by the Philippine Cancer
Society at Provincial or District Health level
on:
– Knowledge of Barangay Health Workers
– Knowledge of mothers
– Inoculation of infants
Hepatitis B and Filipino Infants:
Did I Make the Right Turn?
• Pilot data presented at research conference
• Pilot data needs to lead to future funded
study at R01 level, but first need further
baseline data on number of infants
inoculated to determine need
• Have maintained great interest in the area
• Feel hopeful about impact of research
• Funding interest in Infectious Dis. Is Africa
Acknowledgements
US Fulbright Scholar Program
PAEF
Philippine & American
Cancer Societies
Myrah Lelis
All Project Participants
• Magka-isa Laban sa HBV. Ang Jade Ribbon
ay tiniklop na parang Chinese karakter para sa
lahat “人” na simbolo sa pagkakaisang tinig ng
mamamayan laban sa Hepatitis B at kanser sa
atay sa buong mundo.
• Para sa karagdagan na impormasiyon, bisitahin
ang http://liver.stanford.edu Asian Liver Center
Hepatitis B and Filipino Infants
Thank You