Though universal hepatitis B (HB) immunization has been recommended by the WorId Health Organization(1) and the Indian Academy of Pediatrics(2), it is not a part of India's Universal Immunization Programme (UIP). HB vaccine is being administered only in the private sector to those who voluntarily seek it (and can afford it). While DIP vaccine coverage estimates are available, no HB vaccine coverage figures are available till date.

We did a standard EPI 3D-cluster survey(3) to estimate the coverage of HB and routine vaccines, and assess awareness about HB vaccine. The population based study was done in 38 blocks of Anna Nagar (population of 38,243), an urban, middle/ upper class population of Chennai city in 1997. Data was analyzed using Epi Info software using methods appropriate for cluster sampling(4).

In our population, the UIP vaccine coverage figures were 98%, 98%, 99% and 96% for BCG, DPT3, OPV3 and Measles, respectively. HB vaccine coverage for 3 doses was 42.8% (95% Confidence Interval 33.9-51.7). Private sector utilization was very high for UIP vaccines (92%-96%) and exclusive for HB vaccine (100%). Since only a selected, middle/upper class population was surveyed, we can not generalize our results. As we did not collect data on the exact timing of the HB vaccine doses, it is unclear as to what proportion got the first dose at birth.

Only 85 (40%) of 210 mothers reported that they knew there were different types of jaundice. However, 138 (66%) had heard of hepatitis B. When asked whether they knew that there was a vaccine to prevent jaundice, 172 (82%) replied "Yes". Some mothers who had never heard of hepatitis B had also vaccinated their babies (by immunization card). Of those who had given at least one HB dose (n = 114), 93 (82%) reported doctors as their source of knowledge about the vaccine. Of the mothers who had given HB vaccination, 94 (82%) did not know the mode of spread of hepatitis B or reported it incorrectly. A majority of the mothers (92%) who had vaccinated their babies felt that HB vaccine was equally or more important than VIP vaccines.

Awareness of the types of hepatitis vi- ruses and their modes of spread was poor considering the high level of education and socioeconomic status of the population. This was true even of educated parents. This matters because HB vaccine offers no protection against the other hepatitis viruses, and if a vaccinated child develops jaundice, poorly informed parents may lose confidence in the vaccine and this may adversely affect vaccine acceptance. In fact, many mothers knew that their children had got "jaundice vaccines" but had no idea as to what type of hepatitis they prevented.
In conclusion, HB vaccination may be gaining acceptance among the middle and upper classes and this may slowly influence acceptance in the other strata. Education is needed to improve awareness and practices regarding the vaccine. Education (targeting mothers) should precede the introduction of HB vaccine into the VIP for maximum impact. Since private practitioners appear to be the major source of immunization and education, they could be enlisted for health education. They need to educate mothers about HBV and its vaccine and not merely promote it as "jaundice vaccine."
 

Madhukar Pai,
Premkumar Sundaram,
K.K. Radhakrishnan,
Kuruvilla Thomas,
Jayaprakash Muliyil,
Departments of Community Medicine and
Epidemiology and Pediatrics,
Dr. Rangarajan Memorial Hospital,
Sundaram Medical Foundation
Anna Nagar, Chennai 600 040
and Department of Community Health,
Christian Medical College,
Vellore 632 002, India.