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
Natl 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


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)
ORGANIZATIONAL CHART
Philippine DOH
(Central) Manila
DOH CHD-
Region 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, 1
st
dose given
ASAP after birth + HB immune globulin if available
and/or affordable
**2
nd
, 3
rd
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 govt, 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 2
nd
, 3
rd
dose follow-
ups 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 1
st
, 2
nd
and 3
rd
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

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 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