International Journal of Public Health

, Volume 57, Issue 3, pp 581–588 | Cite as

A model program for hepatitis B vaccination and education of schoolchildren in rural China

  • Jonathan J. Chen
  • Ellen T. Chang
  • Yi-Ren Chen
  • Meredith B. Bailey
  • Samuel K. S. So
Original Article



Incomplete hepatitis B virus (HBV) vaccine coverage and poor HBV-related knowledge in China leave millions of children unprotected from this life-threatening infection. To address these gaps, a pilot program for HBV education and vaccination was launched in rural China.


In 2006, public and private organizations in the US and China collaborated to provide HBV education and vaccination to 55,000 school-age children in the remote, highly HBV-endemic area of Qinghai Province. The impact of the educational program on HBV-related knowledge was evaluated among more than 2,800 elementary school students.


Between September 2006 and March 2007, the three-shot hepatitis B vaccine series was administered to 54,680 students, with a completion rate of 99.4%. From low pre-existing knowledge levels, classroom educational sessions statistically significantly increased knowledge about HBV risks, symptoms, transmission, and prevention.


This program offers an effective and sustainable model for HBV catch-up vaccination and education that can be replicated throughout China, as well as in other underserved HBV-endemic regions, as a strategy to reduce chronic HBV infection, liver failure, and liver cancer.


Hepatitis B Vaccine Education China 



This project was supported by a donation from the ZeShan Foundation (Hong Kong) and by the Asian Liver Center at Stanford University through private donations. The authors thank Jordan Su for her work on coordinating this project.


  1. Altice FL, Bruce RD, Walton MR, Buitrago MI (2005) Adherence to hepatitis B virus vaccination at syringe exchange sites. J Urban Health 82(1):151–161PubMedCrossRefGoogle Scholar
  2. Campbell JV, Garfein RS, Thiede H, Hagan H, Ouellet LJ, Golub ET, Hudson SM, Ompad DC, Weinbaum C (2007) Convenience is the key to hepatitis A and B vaccination uptake among young adult injection drug users. Drug Alcohol Depend 91(Suppl 1):S56–63Google Scholar
  3. Centers for Disease Control and Prevention (CDC) (2005) A comprehensive immunization 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 Rep 54(RR-16):1–31Google Scholar
  4. Centers for Disease Control and Prevention (CDC) (2006) A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 55(RR-16):1–33 quiz CE31-34Google Scholar
  5. Centers for Disease Control and Prevention (CDC) (2007) Progress in hepatitis B prevention through universal infant vaccination—China, 1997–2006. MMWR Morb Mortal Wkly Rep 56(18):441–445Google Scholar
  6. Chang ET, Sue E, Zola J, So SK (2009) 3 For Life: a model pilot program to prevent hepatitis B virus infection and liver cancer in Asian and Pacific Islander Americans. Am J Health Promot 23(3):176–181PubMedCrossRefGoogle Scholar
  7. Chao J, Chang ET, So SK (2010) Hepatitis B and liver cancer knowledge and practices among healthcare and public health professionals in China: a cross-sectional study. BMC Public Health 10:98. doi: 10.1186/1471-2458-10-98 PubMedCrossRefGoogle Scholar
  8. China Digital Times (2009) China news tagged with: hepatitis B. Last updated 29 Dec 2009
  9. Cui FQ, Miao N, Hu YS (2009) Effect of hepatitis health promotion project in schools of Beijing and Gansu. Zhongguo Ji Hua Mian Yi 15(5):409–416PubMedGoogle Scholar
  10. Cui F, Li L, Hadler SC, Wang F, Zheng H, Chen Y, Gong X, Hutin YJ, Cairns KL, Liang X, Yang W (2010) Factors associated with effectiveness of the first dose of hepatitis B vaccine in China: 1992–2005. Vaccine 28(37):5973–5978. doi: 10.1016/j.vaccine.2010.06.111 PubMedCrossRefGoogle Scholar
  11. Curado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, Boyle P (2007) Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160. International Agency for Research on Cancer (IARC), LyonGoogle Scholar
  12. Custer B, Sullivan SD, Hazlet TK, Iloeje U, Veenstra DL, Kowdley KV (2004) Global epidemiology of hepatitis B virus. J Clin Gastroenterol 38(10 Suppl):S158–S168PubMedCrossRefGoogle Scholar
  13. Doebbeling BN, Ferguson KJ, Kohout FJ (1996) Predictors of hepatitis B vaccine acceptance in health care workers. Med Care 34(1):58–72PubMedCrossRefGoogle Scholar
  14. Foggin PM, Torrance ME, Dorje D, Xuri W, Marc Foggin J, Torrance J (2006) Assessment of the health status and risk factors of Kham Tibetan pastoralists in the alpine grasslands of the Tibetan plateau. Soc Sci Med 63(9):2512–2532. doi: 10.1016/j.socscimed.2006.06.018 PubMedCrossRefGoogle Scholar
  15. Goldstein ST, Zhou F, Hadler SC, Bell BP, Mast EE, Margolis HS (2005) A mathematical model to estimate global hepatitis B disease burden and vaccination impact. Int J Epidemiol 34(6):1329–1339PubMedCrossRefGoogle Scholar
  16. Gust ID (1996) Epidemiology of hepatitis B infection in the Western Pacific and South East Asia. Gut 38(Suppl 2):S18–S23PubMedCrossRefGoogle Scholar
  17. Hutton DW, So SK, Brandeau ML (2010) Cost-effectiveness of nationwide hepatitis B catch-up vaccination among children and adolescents in China. Hepatology 51(2):405–414. doi: 10.1002/hep.23310 PubMedCrossRefGoogle Scholar
  18. International Fund for Agricultural Development (IFAD) (2011) China: Qinghai/Hainan Prefecture Agricultural Development Project. Accessed 03/01/2011
  19. Juan S (2009) Hepatitis B tests for jobs set to stop. In China Daily (online). Available at:
  20. Juan S, Yao L (2011) Pregnant women to be tested for disease. Available at: Last updated 1 March 2011. China Daily
  21. Kane MA (2003) Global control of primary hepatocellular carcinoma with hepatitis B vaccine: the contributions of research in Taiwan. Cancer Epidemiol Biomarkers Prev 12(1):2–3PubMedGoogle Scholar
  22. Li H, Liu CJ, Li FQ (2009) The analysis on the hepatitis B awareness and factors influencing of reproductive women in poverty rural areas of Gansu province. Zhongguo Ji Hua Mian Yi 15(3):263–266PubMedGoogle Scholar
  23. Liu J, Fan D (2007) Hepatitis B in China. Lancet 369(9573):1582–1583PubMedCrossRefGoogle Scholar
  24. Louther J, Feldman J, Rivera P, Villa N, DeHovitz J, Sepkowitz KA (1998) Hepatitis B vaccination program at a New York City hospital: seroprevalence, seroconversion, and declination. Am J Infect Control 26(4):423–427PubMedCrossRefGoogle Scholar
  25. Qinghai Provincial Investment Promotion Bureau (2010) Qinghai in brief. Last updated 31 March 2010
  26. Sansom S, Rudy E, Strine T, Douglas W (2003) Hepatitis A and B vaccination in a sexually transmitted disease clinic for men who have sex with men. Sex Transm Dis 30(9):685–688PubMedCrossRefGoogle Scholar
  27. Shepard CW, Simard EP, Finelli L, Fiore AE, Bell BP (2006) Hepatitis B virus infection: epidemiology and vaccination. Epidemiol Rev 28:112–125PubMedCrossRefGoogle Scholar
  28. Skinner SR, Imberger A, Nolan T, Lester R, Glover S, Bowes G (2000) Randomised controlled trial of an educational strategy to increase school-based adolescent hepatitis B vaccination. Aust N Z J Public Health 24(3):298–304PubMedCrossRefGoogle Scholar
  29. The Economist (2006) Hepatitis B in China: B is for bigotry. Available at:
  30. United States Census Bureau, Population Division/International Programs Center (2010) International Data Base (IDB) Population Pyramids. Last updated 19 March 2010
  31. Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, Neitzel SM, Ward JW (2008) Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep 57(RR-8):1–20PubMedGoogle Scholar
  32. Wilson T, Harman S (2000) Analysis of a bi-state, multi-district, school-based hepatitis B immunization program. J school health 70(10):408–412PubMedCrossRefGoogle Scholar
  33. World Health Organization (WHO) (2007) Western Pacific regional plan for hepatitis B control through immunization. WHO Regional Office for the Western Pacific, Manila, PhilippinesGoogle Scholar
  34. World Health Organization (WHO) (2008a) Hepatitis B Fact Sheet No. 204. Available at: World Health Organization, Geneva
  35. World Health Organization (WHO) (2008b) World Malaria Report 2008. Annex 3B. Available at: World Health Organization, Geneva
  36. World Health Organization (WHO) (2009) WHO Report 2009. Global Tuberculosis Control. Country Profile: China. Available at:
  37. World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Joint United Nations Programme on HIV/AIDS (UNAIDS) (2006) Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: China. Available at: World Health Organization, Geneva
  38. Xia GL, Liu CB, Cao HL, Bi SL, Zhan MY, Su CA, Nan JH, Qi XQ (1996) Prevalence of hepatitis B and C virus infections in the general Chinese population. Results from a nationwide cross-sectional seroepidemologic study of hepatitis A, B, C, D, and E virus infections in China, 1992. Int Hepat Commn 5:62–73CrossRefGoogle Scholar
  39. Xinhua Economic News Service (March 5, 2009) Survey: Implicit discrimination against Chinese Hepatitis B carriers rising in multinationals Available at: Last updated: 05 March 2009, Last Accessed 30 March 2009
  40. Xu Y, Liu XZ, Li YD (2009) Evaluation on health education of hepatitis B control and prevention in reproductive age women in rural areas. Zhongguo Ji Hua Mian Yi 15(3):259–262PubMedGoogle Scholar
  41. Yao GB (1996) Importance of perinatal versus horizontal transmission of hepatitis B virus infection in China. Gut 38(Suppl 2):S39–S42PubMedCrossRefGoogle Scholar
  42. Zhiqiang G, Zhaohui D, Qinhuan W, Dexian C, Yunyun F, Hongtao L, Iloeje UH (2004) Cost of chronic hepatitis B infection in China. J Clin Gastroenterol 38(10 Suppl):S175–S178PubMedCrossRefGoogle Scholar

Copyright information

© Swiss School of Public Health 2011

Authors and Affiliations

  • Jonathan J. Chen
    • 1
  • Ellen T. Chang
    • 1
    • 2
    • 3
  • Yi-Ren Chen
    • 1
    • 3
  • Meredith B. Bailey
    • 1
  • Samuel K. S. So
    • 1
    • 3
  1. 1.Asian Liver Center at Stanford UniversityPalo AltoUSA
  2. 2.Cancer Prevention Institute of CaliforniaFremontUSA
  3. 3.Stanford University School of MedicineStanfordUSA

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