Keeping the Passion Alive: Making the Right Turn Geraldine Padilla, PhD Professor and Associate Dean UCSF School of Nursing

Keeping the Passion Alive: Making the Right Turn

Geraldine Padilla, PhDProfessor and Associate DeanUCSF 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% & aboveHigh: 8% & above Intermediate: 2-8%Intermediate: 2-8% Low: Below 2%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


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)


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


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


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


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 InfantsProcedures 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)


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 volunteerl


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


HBV Immunization Study: ResultsImpact 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 InfantsHBV Immunization Study: Results, 23 locationsWritten policy on hand 2 Rural 2 Semi-rural 6 Urban

No written policyon hand 2 Rural 2 Semi-rural 7 Urban 2 NA


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


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 locationsFactors 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

follow-ups with tracking through immunization cards & designated personnel


21 applicable locationsBarriers 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


30 Health Care Providers

•Knowledge about vaccine integrity: All 30

•Knowledge about Hep B infant inoculation policy: Knowledge deficit among some health professionals


30 Health Care ProvidersType 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


30 Health Care ProvidersPersonal knowledge of

vaccine availability policy•27 knowledgeable•3 ignorant


30 Health Care ProvidersKnowledge & 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 InfantsHBV 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


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


Research NeededImprove knowledge of & adherence to HBV infant inoculation policy among health care providers

Identify strategies to assist mothers to adhere to inoculation schedule


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 ProgramPAEFPhilippine & American

Cancer SocietiesMyrah LelisAll 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

http://liver.stanford.edu/


Thank You

Documents

Keeping the Passion Alive: Making the Right Turn Geraldine Padilla, PhD Professor and Associate Dean UCSF School of Nursing