Vaccine xxx (xxxx) xxx

Contents lists available at ScienceDirect

Vaccine

j o u r n a l h o m e p a g e : w w w . e l s ev i e r . c o m / l o c a t e / v a c c i n e

Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at
routine immunization clinics in Enugu State – Nigeria
a,e,⇑ b b
Uchechukwu Joel Okenwa , Magbagbeola David Dairo , Eniola Bamgboye ,
a,c,d
Olufemi Ajumobi
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
cSchool of Community Health Sciences, University of Nevada, Reno, United States
d Federal Ministry of Health, Abuja, Nigeria
eEnugu State Ministry of Health, Enugu, Nigeria

article info abstract

Article history: Background: World Health Organization recommends hepatitis B vaccine birth dose for all infants within 24 hours of birth as
Received 17 July 2019 the most cost-effective measure to prevent perinatal hepatitis B virus infection (HBV). We assessed and identified the
Received in revised form 14 November 2019
predictors of maternal knowledge and infants’ uptake of valid hepatitis B vaccine birth dose (HepB-BD).
Accepted 14 January 2020 Available online xxxx
Methods: We conducted a hospital-based cross-sectional survey among 344 mother-infant attendees of routine immunization
clinics selected by multi-stage sampling technique in Enugu State, Nigeria. We col-lected data on socio-demographic
Keywords:
characteristics, delivery history, maternal knowledge and infant’s receipt of valid HepB-BD with interviewer-administered
Hepatitis B vaccine birth dose
questionnaire. Maternal knowledge was assessed using nine domain questions. Overall, good knowledge was defined as a
Health facilities
Infant score of 50%. Only infants who received first hepatitis B dose within 24 hours were considered to have received valid BD. We
Mothers calculated frequencies, performed Chi square test and logistic regression.
Routine immunization
Nigeria Results: One hundred and two (29.7%) mothers knew HBV can be transmitted from mother to child; 119 (34.6%) and 156
(45.3%) knew their infant should receive valid HepB-BD and four doses for full immu-nization of HepB respectively. Overall,
114 (31.1%) mothers had good knowledge of HBV and 88 (26.9%) of 327 who delivered at the health facilities had valid
HepB-BD. Predictors of maternal knowledge were attainment of tertiary education (adjusted Odds Ratio (aOR): 2.1, 95%CI:
1.3–3.5) and living in rural areas (aOR: 0.5, 95%CI: 0.3–0.9). Predictors of valid HepB-BD uptake were maternal knowledge
(aOR: 2.4, 95%CI: 1.4–4.0) and delivery at facilities offering routine immunization services (aOR: 5.4, 95%CI: 2.5– 11.9).

Conclusion: Knowledge and uptake of valid HepB-BD were low. Health education on benefits of valid HepB-BD was given to
mothers after administration of questionnaires. We disseminated findings to the State Ministry of Health and recommended
integration of child delivery and immunization services for birth dose vaccines especially valid HepB-BD.

2020 Elsevier Ltd. All rights reserved.

1. Background Africa [1]. In Nigeria, the prevalence remains high at 13.7% with
approximately 19 million Nigerians chronically infected [3]. The risk of
The burden of hepatitis B virus (HBV) infection is still high espe-cially in developing chronic HBV infection is greatest (90%) in infected infants;
sub-Saharan Africa, despite the availability of a safe and effective vaccine for though <5% in persons aged five years and above [4,5]. Mother-to-child-
more than two decades [1]. It is estimated to account for 87,890 deaths transmission is the major route of transmis-sion of HBV infection in Nigeria
annually in sub-Saharan Africa [2]. It also accounted for more than 75% of [4,5]. Perinatal transmission of HBV, therefore, is the greatest risk for the
hepatocellular cancers in development of chronic HBV infection [5,6].

Administration of hepatitis B vaccine birth dose (HepB-BD) to all

⇑ Corresponding author at: Nigeria Field Epidemiology and Laboratory Training Program,
newborns within 24 hours of birth is the most cost-effective measure to
Abuja, Nigeria.
E-mail address: okexta@yahoo.com (U.J. Okenwa). prevent perinatal HBV infection. Hepatitis B vaccine

https://doi.org/10.1016/j.vaccine.2020.01.044
0264-410X/ 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
2 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx

birth dose, unlike other birth dose vaccines such as BCG and OPVO, is a selected from 18 different wards spanning six of the 17 LGAs of Enugu state,
post-exposure prophylaxis [6]. It has 80%–95% efficacy in pre-venting South-east, Nigeria [12].
mother-to-child transmission of HBV [4,6]. This efficacy, however, declines
with increasing interval between birth and the receipt of the vaccine. Hence, 2.3. Sample size calculation and sampling technique
like any other infant post-exposure prophylaxis, its efficacy and effectiveness
are time-bound. The risk of an infant acquiring positive Hepatitis B surface The estimated sample size (N = 366) for the study was calcu-lated using
antigen (HBsAg) from an infected mother increases about eight times when 2 2)
formula for cross-sectional study (n = Z p(1 p)/d with 31% Enugu State’s
the HepB vaccine birth dose is administered after seven days of birth valid HepB-BD coverage [13] and 10% non-response rate factor. Mother-
compared to when it is given within the first three days of life [6]. infant pairs were selected using multi-stage probability sampling technique.
Consequently, the World Health Organization recommends the receipt of a In the first stage, a simple random sampling by balloting was used to select
birth dose of hepatitis B vaccine by all infants as soon as possible after birth, two LGAs from each of the three senatorial districts. Stage 2: the wards in
preferably within 24 hours (valid dose) [5,6]. each of the six selected LGAs were stratified into urban and rural; one urban
and two rural wards were selected per LGA using simple random sampling by
balloting. Stage 3: one health facility was selected from each of the 18 wards
Unfortunately, the awareness of the recommended time for receipt of using simple random sampling by balloting. Stage 4: Finally, 366 mother-
valid HepB-BD is still poor among the mothers who most of the time were infant pairs were selected using systematic sampling method, see Fig. 1.
responsible for taking these infants to immuniza-tion offering facilities [7].
Studies in South-west, North-central and South-south Nigeria showed that
poor maternal knowledge, having below tertiary education and absence of felt
need were hindrances to immunization uptake, resulting generally in poor 2.3.1. Selection of mother-infant pairs
coverage of vaccines [8–10]. A previous study in Benin, South-south Nigeria Using a probability proportional to size, the proportion of mother-infant
revealed 1.3% uptake of a valid HepB-BD among attendees of immunization pairs in a facility per month (n) was calculated from the total average number
clinics [11]. However, to our knowledge there is no available data for South- and a sample frame of 1039 [12]. The details were provided in a study on
east Nigeria. maternal reasons for non-receipt of hepatitis B birth dose among mothers
attending immu-nization clinics in Enugu State [12]. The mother-infant pairs
In order to avert the inherent risk of mother-to-child-transmission of were recruited at each immunization session of the selected health facil-ity for
HBV, as part of a larger study [12], we assessed the knowledge and uptake of a period of one month. This was to ensure that the monthly target population
valid HepB-BD among attendees of routine immunization clinics in Enugu of the health facility was covered, see Table 1.
State, South-east Nigeria and identified their predictors.

2.4. Data collection

2. Methods A pretested structured interviewer-administered questionnaire was used to

collect information on socio-demographic characteris-tics of the mothers,
2.1. Study area their delivery history, maternal knowledge and infant’s receipt of valid HepB-
BD (N = 366). Data on infants’ date of birth and time of receipt of hepatitis B
This study was conducted at health facilities offering routine birth dose were confirmed using the infants’ immunization card. The
immunization in Enugu State, South-east Nigeria from October 2017 to questionnaires were administered by six trained research assistants.
January 2018. Enugu State has 291 wards, an estimated total population of
4,508,862 and 180,354 infants (projected from 2006 census population). It is
made up of five urban and 12 rural local government areas (LGAs). The state 2.5. Data processing and analysis
is divided into three sen-atorial districts, namely; Enugu-north (6 LGAs),
Enugu-east (6 LGAs) and Enugu-west (5 LGAs). It has 602 health facilities Data entry, cleaning and analysis were conducted using Epi-info version
(public, mission and private hospitals) offering routine immunization ser- 7.2 and Microsoft Excel. To assess maternal knowledge, responses to nine
vices. Immunization sessions in each health facility depends on the target knowledge-domain questions were scored. Each correct response was scored
population for infants residing in areas served by the facility. The average one point while an incorrect or a ‘Don’t know’ response was scored zero.
number of immunization sessions or days of the health facilities is four times Scores of <50% were graded as poor knowledge and those of 50% and above
in a month, that is once in a week. At the start of each routine immunization as good knowledge. Valid birth dose was defined as the receipt of the first
session, ‘health-talks’ are given to the attendees by the health care workers. dose of hepatitis B vaccine within 24-hours of birth. Maternal age was
The immuniza-tion cards of the infants are retrieved from the attendees and presented in mean and standard deviation. Univariate analysis was conducted
nec-essary documentation is made on the immunization register and the to obtain frequencies and percentages. Categorical variables were compared
infant’s card. New child immunization card is issued to the fresh attendees. using Chi-squared test. Predictors of maternal knowledge and valid HepB-BD
Information recorded in each card include: infant’s name, sex, date of birth, uptake were ascertained at unconditional logistic regression. Results of
vaccination schedule, address of parents, growth monitoring charts, vaccines bivariate and multivariate analyses were presented using crude odds ratio
given with dates and a date for next immunization. (COR) and adjusted odd ratios (aOR) respectively at 95% confidence interval
(CI).

2.6. Ethical consideration

2.2. Study design and population
The ethical approval for the study was obtained from the Research Ethics
A hospital-based cross-sectional survey was conducted among mothers of Committee of Enugu State Ministry of Health, (ref-erence number
infants attending routine immunization clinics. The study population were MH/MSD/REC/0238, date: 20th July 2017). At enrolment, informed consent
part of a larger study of mother-infant pairs attending routine immunization was obtained from each participant after explaination of the essence of the
clinics in 18 health facilities study. Information on study

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx 3

Fig. 1. Flow chart of sampling strategy of mother-infants’ pairs attending immunization clinics, Enugu State, Nigeria.

participants was anonymized at data entry and analysis. The prin-cipal son to another. Moreover, 119 (34.6%) and 156 (45.3%) knew their infant
investigator had sole access to the study data which were stored in password- should receive the first dose of HepB at birth and four doses for full
protected computer. immunization of HepB respectively and 9 (2.6%) knew the correct schedule
for HepB vaccine, see Table 3. Overall, 114 (33.1%) mothers had good
knowledge of HBV infection and vacci-nation while 90 (26.2%) infants had
3. Results
received valid doses of hepati-tis B vaccine. Of the 327 (95.1%) infants
delivered at health facility, 88 (26.9%) had valid HepB-BD. Having had
3.1. Socio-demographic and delivery characteristics tertiary education as a mother (Crude odds ratio (COR): 2.55, CI: 1.58–4.11)
and living in rural areas (COR:0.45, CI:0.29–0.71) were associated with good
Overall, 366 mother-infant pairs were interviewed but 22 ques-tionnaires knowledge of HBV infection and its vaccination. The overall good maternal
had incomplete information. Data from a total of 344 mother-infant pairs with knowledge (COR: 2.86, CI:1.74–4.71), delivery at public health facilities
a mean age of 27.8 ± 4.7 years were ana-lyzed. Two hundred and thirty-one (COR:2.31, CI:1.41–3.79) and at facilities offering routine immunization
(67.2%) mothers were between 25 and 34 years, 154 (44.8%) reside in rural services (COR:6.62, CI:3.28–13.36) were sig-nificantly associated with valid
area, 331 (96.2%) were currently married and 104 (30.2%) had attained HepB-BD uptake, see Table 4.
tertiary education. Overall, 327 (95.1%) infants were delivered at health
facilities out of which 143 (43.7%) were delivered at public health facilities.
Those delivered at facility offering routine immunization services were 219
(63.7%), see Table 2. 3.3. Predictors of good knowledge of hepatitis B virus, its vaccination and
uptake of valid hepatitis B vaccine birth dose among mothers of infants

3.2. Awareness, knowledge and uptake of hepatitis B among mothers of

infants Tertiary education attainment (adjusted Odds Ratio (aOR: 2.10,
CI: 1.28–3.46) and living in rural areas (aOR: 0.45, CI: 0.29–0.89)
Mothers who have heard of HBV infection were 258 (75.0%). One were predictors of good maternal knowledge of HBV infection
hundred and two (29.7%) and 83 (24.1%) knew that it can be transmitted and its vaccine, see Table 4. Predictors of valid hepatitis B vaccine
from mother to child and from apparently healthy per- birth dose were mothers who had overall good knowledge of HBV

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
4 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx

Table 1
Sampling of mother-infant pairs by probability proportional to size (PPS), Enugu State, Nigeria.
+
LGA Ward Health facility Average No of Proportion No of mother- No of No of mother-
mother-infant pairs infant immunization infant
in a month (N) pairs allocated sessions in a pairs allocated
in a month (n) month in a session
N n B C = n/B
Awgu Awgu 1 MCH Awgu 100 (100/1039) 366 = 35 35 4 9
Mgbowo Mgbowo PHC 70 (70/1039) 366 = 25 25 4 6
Awgu 2 Ugwulesi PHC 93 (93/1039) 366 = 33 33 4 8
Udi Udi Agbudu MCH Udi 50 (50/1039) 366 = 18 18 4 4
Ngwo-uno Model PHC Ngwo-uno 48 (48/1039) 366 = 17 17 4 4
Abor Abor PHC 30 (30/1039) 366 = 11 11 4 3
Enugu-east Abakpa 1 Abakpa PHC 200 (200/1039) 366 = 70 70 8 9
Emene Chukwuasokam hospital 44 (44/1039) 366 = 15 15 4 4
Mburujodo 2 Onuogba PHC 27 (27/1039) 366 = 10 10 4 2
Enugu- Uwani-East Uwani PHC 84 (84/1039) 366 = 30 30 8 4
South Ugwuaji Eke Ugwuaji PHC 31 (31/1039) 366 = 11 11 4 3
Amaechi-East Amaechi PHC 20 (20/1039) 366 = 7 7 4 2
Udenu Obollo-Afor Obollo-afor PHC 58 (58/1039) 366 = 20 20 4 5
Orba 2 Model PHC Orba 42 (42/1039) 366 = 15 15 4 4
Amalla Early-bird clinic, Amalla Egazi 54 (54/1039) 366 = 19 19 2 10
Nsukka Owerre umuoyo Nsukka PHC 47 (47/1039) 366 = 17 17 4 4
Ibagwa-ani Ibagwa –ani PHC 20 (20/1039) 366 = 7 7 1 7
Diogbe-ozalla Opi PHC 21 (21/1039) 366 = 7 7 4 2
1039 366

+ = Local Government Area.

infection and its vaccine (aOR: 2.36, CI: 1.38–4.03) and delivery at health routine immunization clinics in Enugu State, South-east Nigeria. Though the
facility offering immunization services (aOR:5.39, CI: 2.45– 11.87), see awareness of hepatitis B infection was high, an in-depth knowledge which
Table 4. would facilitate the demand for valid hepatitis B vaccination was lacking. In
this study, knowledge of HBV transmission, timing of HepB vaccination and
4. Discussion number of doses scheduled for HepB vaccine were poor. Knowledge of
national schedule for HepB vaccine was extremely poor. The study showed
This was a study to assess the maternal knowledge and infant uptake of that most of the mothers did not know HBV infection can
valid hepatitis B vaccine birth dose among attendees of

Table 2 Table 3
Socio-demographic and delivery characteristics of mothers of infants attending immunization Knowledge of hepatitis B among mothers of infants attending routine immunization clinics,
clinics in Enugu State, Nigeria (N = 344). Enugu State, Nigeria (N = 344).
Characteristics Frequency (n) Percentage (%) Knowledge domain Frequency(n) Percentage (%)
Age group (years) Heard of hepatitis B infection 258 75.0
15–24 83 24.1 Knew hepatitis B can be transmitted from 102 29.7
25–34 231 67.2 mother to child
35–44 30 8.7 Knew hepatitis B can be transmitted by 83 24.1
Marital Status someone who looks healthy
Single 12 3.5 Age a child should commence vaccination
Currently married 331 96.2 First day of birth 220 63.9
Divorced/Widowed 1 0.3 2nd–7th day 50 14.5
Educational level 8th–14th day 26 7.6
No formal education 4 1.2 Don’t know 48 13.9
Primary School 26 7.6 Recommended time for hepatitis B first dose
Secondary School 210 61.1 First day of birth 119 34.6
Tertiary School 104 30.2 2nd–7th day 41 11.9
Type of residence 8th–14th day 91 26.5
Urban 190 55.2 Don’t know 93 27.0
Rural 154 44.8 Reason for giving birth dose at birth
Infant’s place of delivery To protect the infants from chronic 223 64.8
Private health facility 184 53.5 hepatitis B infection
Tertiary health facility 35 10.2 To protect the infants from HIV infection 21 6.1
Secondary health facility 23 6.7 For treatment of Hep-B infection 45 13.1
Primary health facility 85 24.7 To prevent congenital malformation 32 9.3
At home 10 2.9 Don’t know 23 6.7
Traditional birth attendant centre 7 2.0 Total number of hepatitis B doses for a child
Day/period of current child birth 4 doses (Correct response) 156 45.3
Weekend/Public holidays 111 32.3 More than 4 doses 188 54.7
Working days of the week 233 67.7 Knew the schedule of hepatitis B 9 2.6
Delivery at health facility offering 219 63.7 Knew of a vaccine to prevent hepatitis B 167 48.6
immunization infection in adults

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx 5

Table 4
Predictors of hepatitis B infection, its vaccination and uptake of valid hepatitis B birth dose among mothers attending routine immunization clinics in Enugu State, Nigeria.

Characteristics Knowledge Valid Hepatitis B birth dose

Good Poor COR aOR Yes No COR aOR

N (%) N (%) (95% CI) (95% CI) N (%) N (%) (95% CI) (95% CI)

Age (years)
<30 72 (63.2) 154 (67.0) 0.85 – 60 (66.7) 166 (65.4) 1.06 –
30 and above 42 (36.8) 76 (33.0) (0.53–1.35) 30 (33.3) 88 (34.6) (0.64–1.74)
Marital Status
Currently married 112 (98.3) 219 (95.2) 2.81 – 87 (96.7) 244 (96.1) 1.19 –
Not married 2 (1.7) 11 (4.8) (0.61–12.9) 3 (3.33) 10 (3.9) (0.32–4.42)
Educational level
Tertiary 50 (43.9) 54 (23.5) 2.55 2.10 35 (38.9) 69 (27.2) 1.70 1.21
n
Below Tertiary 64 (56.1) 176 (76.5) (1.58–4.11)* (1.28–3.46)* 55 (61.1) 185 (72.8) (1.03–2.83)* (0.69–2.11)
Residence
Rural 48 (42.1) 142 (61.7) 0.45 0.55 42 (46.7) 148 (58.3) 0.63 –
Urban 66 (57.9) 88 (38.3) (0.29–0.71)* (0.34–0.89)* 48 (53.3) 106 (41.7) (0.39–1.02)
Place of delivery
Public health facility 54 (47.8) 89 (40.3) 1.36 – 51 (58.0) 92 (37.4) 2.31 1.30
n
Private health facility 59 (52.2) 132 (59.7) (0.86–2.14) 37 (42.0) 154 (62.6) (1.41–3.79)* (0.74–2.27)
Delivery at HF offering immunization
Yes 88 (77.2) 131 (57.0) 2.56 2.20 80 (88.9) 139 (54.7) 6.62 5.39
No 26 (22.8) 99 (43.0) (1.53–4.26)* (1.30–3.72)* 10 (11.1) 115 (45.3) (3.28–13.36)* (2.45–11.87)*
Mothers’ overall knowledge
Good NA NA NA NA 46 (51.1) 68 (26.8) 2.86 2.36
Poor NA NA 44 (48.9) 186 (73.2) (1.74–4.71)* (1.38–4.03)*
n
* = statistically significant at 95% CI; = not statistically significant; NA = not applicable; COR = crude odds ratio; aOR = adjusted odds ratio; CI = confidence interval; HF = health facility.

be transmitted to the child from the mother and from an appar-ently healthy especially mothers is a very important characteristic and has been linked with
person to another. This finding is similar to what was seen in other studies other factors that have a significant impact on health-seeking behaviours,
[14,15]. children’s health status, etc. [19]. Mother’s education may likely mediate
While Only about two-thirds of mothers were aware it should be given to increase in uptake of vaccination from having had increased knowledge of
a day old baby, only a third knew that their infant should receive hepatitis B vaccination. The associa-tion between knowledge and educational level in this
vaccine birth dose on the first day of birth. Less than half of the mothers knew study was consistent with previous studies [14,20–23]. The good knowledge
that a child should receive four doses of hepatitis B vaccine for full observed in those who attained tertiary education could stem from the fact
immunization. The main objective of birth dose vaccines is to prevent that higher educational level is associated with upper socioeconomic status
perinatal transmission of the targeted disease. This is especially important for and thus they find it easy to acquire knowledge from schools, books, journals,
HepB vaccine birth dose as it’s efficacy reduces as the time interval between internet and their social networks. In contrast, living in rural areas was a
the administration of the vaccine and the time of delivery increases [11,16]. negative predictor of knowledge. This could be attributed to limited
Therefore, knowledge of vaccine ben-efits and its timely administration goes resourceful materials on knowledge of health issues generally and lower
a long way in determining its uptake. However, there was an overall low socioeconomic status in rural areas compared to what are obtainable in urban
maternal knowledge of HBV infection and HepB vaccination. This was areas.
similar to the studies done in South-west Nigeria and Cameroun [8,14]. This
low maternal knowledge may result in poor prioritization in ensur-ing that
their infants receive HepB-BD. This portends the need for regular continuous The essence of hepatitis B vaccine birth dose is to prevent peri-natal
baisc education and sensitization about HBV infection, not just for the transmission therefore the delay in the presentation of infants for these doses
mothers but for all care-givers. would put them at a risk of being infected with the diseases. In our study, we
found low infant uptake of valid HepB-BD and less than 25% of those
delivered at the health facili-ties had valid HepB-BD. The uptake was higher
Hepatitis B vaccine birth dose, unlike other birth dose vaccines is given as than the 0.4% and 1.3% found in another study in Benin, Edo State Nigeria
post-exposure prophylaxis and its efficacy reduces as the time interval [11,24]. This difference may be because of different socioeconomic status of
increases between its administration and birth [17]. In Nigeria, the birth dose the caregivers; those studies were done in a tertiary institution while ours
vaccines were scheduled for birth and up to two weeks [18]. This may be involve many health facilities, (>90% are PHCs). Our finding on uptake of
misunderstood by both the health workers and caregivers who do not know valid HepB-BD was quite low compared to the 87% and 97% found in
the rationale for giving hepatitis B vaccine birth dose within 24 hours of birth hospital-based studies in the Philipines and China respectively [25,26] where
and thus would not place emphasis about this. This contributes to the poor there is a policy in place that mandates the vaccination of all newborns few
knowledge and adherence to hepatitis B birth dose tim-ing. Thus it is vital to hours after birth and vaccines are pre-positioned at the labour and or
increase awareness and knowledge of both caregivers and health workers and maternity wards. Overall good knowledge of hepatitis B virus infection and
to emphasize on the need for all infants to receive hepatitis B vaccine birth its vacci-nation, delivery at public health facilities and at facilities offering
dose within 24 hours of birth. immunization services were significantly associated with the uptake of valid
HepB-BD. Predictors of valid HepB-BD were good knowledge and delivery
at facilities offering immunization
Attainment of tertiary education was found to be a positive pre-dictor of
knowledge. The educational level of household members

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
6 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx

services. This finding was consistent with similar studies among mothers Declaration of Competing Interest
[10,27]. The knowledge of mothers/caregivers has been found to have a direct
significant effect on the immunization status of their children [9]. It will also The authors declare that they have no known competing finan-cial
increase the likelihood of mothers requesting for valid HepB-BD for their interests or personal relationships that could have appeared to influence the
newborns. Integrating deliv-ery of the birth dose of hepatitis B vaccine into work reported in this paper.
part of essential newborn care is one of the interventions that could improve
birth dose coverage [28,29]. Delivery at facility offering immunization
services increases the chance of the child receiving valid HepB-BD. Children References
born in other health facilities that do not offer immu-nization services may
not be able to get vaccinated within 24 hours in those health facilities. It is [1] Andersson MI, Rajbhandari R, Kew MC, Vento S, Preiser W, Hoepelman AI, et al.
important to deal with the issue of distance, mother’s knowledge and cost of Mother-to-child transmission of hepatitis B virus in sub-Saharan Africa: time to act. Lancet
transportation to the immunization centers. Timely administration of birth Glob Heal 2015;3:e358–9. https://doi.org/10.1016/S2214-109X (15)00056-X.
dose vacci-nes were found to be inversely associated with distance to vaccina- [2] World Health Organization. Global hepatitis report, 2017; 2017. doi: ISBN 978-92-4-
tion delivery points [30,31]. The implication is, increased risk of mother-to- 156545-5.
child transmission of the infection. The infected infants are not only at risk of [3] Nd U, Eo O. Prevalence and risk factors of hepatitis B virus transmission among children
liver diseases and death but also at risk of transmitting the infection to others. in Enugu, Nigeria. Niger J Paediatr 2015;42:199–203.
[4] WHO. Hepatitis B vaccines WHO position paper. Wkly Epidemiol Rec 2009;84:405–20.

[5] WHO. Hepatitis B vaccines: WHO position paper-recommendations. Vaccine

2010;28:589–90. https://doi.org/10.1016/j.vaccine.2009.10.110.
[6] EPI Team (WHO). Preventing mother-to-child transmission of hepatitis B 2006:1–53.
4.1. Limitations of the study

One of the limitations of this study was it being health facility-based,

[7] Breakwell L, Tevi-Benissan C, Childs L, Mihigo R, Tohme R, Davis R, et al. Cite this:
The Pan African Medical Journal. Pan Afr Med J 2017;27:17. https://doi.
given that community-based studies would have been more representative of org/10.11604/pamj.supp.2017.27.3.11981.
the infant population. Nevertheless, in conduct-ing a community-based study
[8] Adeyemi AB, Enabor OO, Ugwu IA, Bello OOO FA. Knowledge of hepatitis B virus
there is a likelihood of lower results on HepB-BD uptake and this should be infection, access to screening and vaccination among pregnant women in Ibadan, Nigeria. J
taken into consideration. Notably, mothers of the infants seen at the health Obstet Gynaecol (Lahore) 2013:155–9.
facilities are likely to have good health seeking behaviour. Thus, our findings [9] Edomwonyi P, Ubannache B, Busu M. Knowledge, attitude and practice of immunization
are still significant and can be used to draw attention to this seem-ingly processes and its coverage in rural communities of Bida Emirate
neglected aspect of timeliness of vaccination. Area, Niger State, Nigeria. ARC J Nurs Healthc 2015;1:29–37.
[10] Odusanya OO, Alufohai EF, Meurice FP, Ahonkhai VI. Determinants of
vaccination coverage in rural Nigeria. BMC Public Health 2008;8:1–8.
https://doi.org/10.1186/1471-2458-8-381.
5. Conclusion [11] Sadoh AE, Eregie CO. Timeliness and completion rate of immunization among
Nigerian children attending a clinic-based immunization service. J Health Popul Nutr
Knowledge on valid HepB-BD was low among mothers in Enugu State, 2009;27:391–5.
Nigeria. The low knowledge probably affected valid HepB-BD uptake. Health [12] Okenwa UJ, Dairo MD, Uba B, Ajumobi O. Maternal reasons for non-receipt of
education was given to the mothers on the impor-tance of valid HepB-BD valid Hepatitis B birth dose, Enugu State, Nigeria. Vaccine J 2019;1 [in preparation].
after administration of the questionnaires. We disseminated findings to Enugu
[13] National Primary Health Care Development Agency and National Bureau of Statistics.
State Ministry of Health and recommended educating mothers on the Nigeria, National Immunisation Coverage Survey 2016/17, Final Report. Cover V, Surv C
importance of valid HepB-BD, and integration of child delivery and 2016;4:1–137.
immunization ser-vices for birth dose vaccines especially HepB-BD. [14] Frambo AAB, Atashili J, Fon PN, Ndumbe PM. Prevalence of HBsAg and knowledge
about hepatitis B in pregnancy in the Buea Health District, Cameroon: a cross-sectional study;
2014.
[15] Han Z, Yin Y, Zhang Y, Ehrhardt S, Thio CL, Nelson KE, et al. Knowledge of
Authors contributions and attitudes towards hepatitis B and its transmission from mother to child among pregnant
women in Guangdong Province, China. PLoS One 2017;12:1–9.
https://doi.org/10.1371/journal.pone.0178671.
UJO conceptualized and designed the study, conducted the field work,
[16] Centers for Disease Control. Hepatitis B vaccine birthdose practices in a country
analyzed and interpreted the data and wrote draft manu-script. MDD, EB and where hepatitis B is endemic – Laos, December 2011–February 2012. MMWR Morbidity
OA contributed to the study design, provided technical guidance on data Mortal Wkly Rep 2013;62:587–90. https://doi.org/10.1016/ j.adolescence.2009.09.001.
analysis and interpretation. MDD, EB and OA reviewed draft manuscript for
intellectual content. All authors read and approved the manuscript. UJO and [17] Center for Disease Control and Prevention. A comprehensive immunization
OA are guar-antors of the paper. strategy to eliminate transmission of hepatitis B virus infection in the United States
recommendations of the advisory committee on immunization practices (ACIP) Part 1:
Immunization of infants, children, and adolescents. MMWR Recomm Reports 2005;54:1–32.
doi: 54(RR16).
[18] National Programme on Immunization (NPI). Basic guide for routine immunization
Funding service providers. Revised 20. Abuja (Nigeria); 2004.
[19] NDHS. Nigeria demographic and health survey 2013. Niger Demogr Heal Surv 2013 Natl
Popul Comm Fed Repub Niger 2014:1–400.
This study was supported by the United States Centers for Dis-ease [20] Gidado S, Nguku P, Biya O, Waziri NE, Mohammed A, Nsubuga P. Determinants of
Control and Prevention through African Field Epidemiology Network to the routine immunization coverage in Bungudu, Zamfara State, Northern Nigeria, May 2010
Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP) 2014;18:1–5. doi:10.11694/pamj.supp.2014.18.1.4149.
[Cooperative Agreement Number NU2GGH001876]. Its contents are solely [21] Zhou Y, Wang H, Zheng J, Zhu X, Xia W, Hipgrave DB. Coverage of and
the responsibility of the authors and do not necessarily represent the official influences on timely administration of hepatitis B vaccine birth dose in remote rural areas of the
People’s Republic of China. Am J Trop Med Hyg 2009;81:869–74.
views of the United States Centres for Disease Control and Prevention or the
https://doi.org/10.4269/ajtmh.2009.09-0238.
Department of Health and Human Services.
[22] Nankabirwa V, Tylleskär T. Maternal education is associated with vaccination
status of infants less than 6 months in Eastern Uganda: a cohort study. BMC 2010.
[23] Adeyemi AS, Afolabi AF, Adeomi AA. Hepatitis B Virus (HBV) infection in [25] Allison RD, Patel MK, Tohme RA. Hepatitis B vaccine birth dose coverage
pregnancy : knowledge and practice of care providers in Nigeria. Open J Obstetr Gynecol correlates worldwide with rates of institutional deliveries and skilled attendance at birth.
2014:621–7. Vaccine 2017;35. https://doi.org/10.1016/ j.vaccine.2017.06.051.

[24] Sadoh AE, Sadoh WE, Uduebor J, Ekpebe P, Iguodala O. Factors contributing to
delay in commencement of immunisation in Nigerian infants. Tanzan J Health Res 2013;15.
https://doi.org/10.4314/thrb.v15i3.6.

Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044
 U.J. Okenwa et al. / Vaccine xxx (xxxx) xxx 7

[26] Zhang L, Ko S, Lv J, Ji F, Yan B, Xu F, et al. Perinatal hepatitis B prevention [29] Al Awaidy ST, Bawikar SP, Al Busaidy SS, Al Mahrouqi S, Al Baqlani S, Al
program in Shandong Province, China. Hum Vaccin Immunother 2014;10:2755–60. Obaidani I, et al. Progress toward elimination of Hepatitis B virus transmission in Oman: Impact
https://doi.org/10.4161/hv.29648. of Hepatitis B vaccination. Am J Trop Med Hyg 2013;89:811–5.
https://doi.org/10.4269/ajtmh.13-0333.
[27] Adedire EB, Ajayi I, Fawole OI, Ajumobi O, Kasasa S, Wasswa P, et al.
Immunisation coverage and its determinants among children aged 12–23 months in Atakumosa- [30] Miyahara R, Jasseh M, Gomez P, Shimakawa Y, Greenwood B, Keita K, et al.
west district, Osun State Nigeria: a cross-sectional study. BMC Public Health 2016;16:1–8. Barriers to timely administration of birth dose vaccines in The Gambia, West Africa. Vaccine
https://doi.org/10.1186/s12889-016-3531-x. 2016;34:3335–41. https://doi.org/10.1016/j.vaccine.2016.05.017.

[28] Franco E, Bagnato B, Marino MG, Meleleo C, Serino L, Zaratti L, et al. Hepatitis
[31] Okwaraji YB, Mulholland K, Schellenberg J, Andarge G, Admassu M, Edmond
KM. The association between travel time to health facilities and childhood vaccine coverage in
B: Epidemiology and prevention in developing countries. World J Hepatol 2012;4:74–80. rural Ethiopia. A community based cross sectional study. BMC Public Health 2012;12:1.
https://doi.org/10.4254/wjh.v4.i3.74. https://doi.org/10.1186/1471-2458-12-476.
Please cite this article as: U. J. Okenwa, M. D. Dairo, E. Bamgboye et al., Maternal knowledge and infant uptake of valid hepatitis B vaccine birth dose at routine immunization clinics
in Enugu State – Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.044