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Hepatitis B Prevalence Survey
in Lao PDR
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ISBN 978-4-909675-20-0

Table of Contents
Hepatitis B Prevalence Survey in Lao PDR
Table of Contents

03

Hepatitis B Prevalence Survey in Lao PDR

05

Acknowledgements

06

Acronyms

07

Executive Summary08

1. Introduction

10

2. Methods

12

3. Results

16

4. Discussion and recommendations

19

References

21

Annexes23

Annex 1: Selected districts and villages

24

Annex 2: Questionnaire25Annex 3: Informed Consent form

31

Annex 4: Training agenda

34

Annex 5: Supervisors and surveyors

35

Annex 6: Publication with PLOS ONE

37

Lao Version

47

3

4 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

Hepatitis B Prevalence Survey
in Lao PDR

Aknowledgements

Aknowledgements

We gratefully acknowledge the following groups and individuals for theirassistance with this study:
Ministry of Health, Lao PDR		National Immunization Program		

National Center for Laboratory & Epidemiology

National Center for Global Health and Medicine, Japan		

Bureau of International Medical Cooperation		Hepatology Research Center

National Institute of Infectious Diseases, Japan		

Department of Virology II

JICA (Japan International Cooperation Agency) projects
		Capacity Development for Sector-wide Coordination in Health-Phase2		Strengthening Integrated Maternal, Neonatal and Child Health Services

		

Sustainable Development of Human Resource for Health to Improve		

Maternal, Neonatal and Child Health Services

World Health Organization
		Regional Office for the Western Pacific
Lao PDR office

6 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDRAcronyms

Acronyms

C.I.

Confidence interval

DPT-HepB 3

Diphtheria, pertussis, tetanus, hepatitis B vaccine the third dose

EPI

Expanded Programme on Immunization

HB

Hepatitis B

HBsAg

Hepatitis B surface antigen

JICA

Japan International Cooperation Agency

MoH

Ministry of Health, Lao PDR

NCGMNational Center for Global Health and Medicine

NCLE

National Center for Laboratory and Epidemiology, MoH

NIPNational immunization Program, Maternal and Child Health, MoH

PPS

Probability proportionate to size

SBA

Skilled birth attendance

VPD

Vaccine preventable diseases

WHO

World Health Organization

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 7

Executive Summary

Executive Summary

To assess current hepatitis B prevalencesampling, and then two villages were selected

hepatitis B vaccine introduction in Lao PDR,

surveyors randomly selected 21 child-motheramong general population and the impact ofMinistry of Health, Lao PDR, and NCGM planneda serology and questionnaire survey. The survey,
which covers the whole country, was completed

in February 2012. This report summarizes theresults of the survey.

from each district by PPS. In each village (cluster),pairs from resident lists. After explanation ofsurvey purposes, methods, confidentiality policy,
and obtaining informed consent, questionnaireand blood sampling were conducted. Blood

samples were tested HBsAg using Determine®
rapid test.

⿇⿇ Objectives

Primary objectives of the survey aresummarized below.

⿇⿇ Results

A total of 2,016 blood samples (1,008

1. To estimate hepatitis B surface antigen sero-children and 1,008 their mothers) were collected

2. To estimate hepatitis B surface antigen sero-

1.7% (95%C.I.=0.8, 2.6) for children between fiveprevalence among children

prevalence among mothers

3. To evaluate the potential risk factors
⿇⿇ Target ages, areas, and time
Ages

ChildrenMothers

Five to nine year-old
15 to 45 year-old

Areas Whole country

Time

January and February, 2012

⿇⿇ Survey methodologies

and found to have hepatitis B virus prevalence ofto nine years old and 2.9% (95%C.I.=1.6, 4.2) for
their mothers with child bearing age. Mother’s

infection status was positively associated with

their children’s HBsAg positivity, while otherpotential risk factors (mother’s age, ethnicity, timeto the nearest health center, level of mother’s
education, and medical history) were not.
⿇⿇ Discussion and recommendations

This is the first nationwide population-

All 143 districts in Lao PDR were stratified

based hepatitis B sero-prevalence survey in Lao

hepatitis B immunization coverage reported

lower than the results from surrounding countries.

into two categories; high and low third DPT-in 2010. 12 districts from each stratum wereselected by probability proportionate to size (PPS)PDR. The prevalence results of the survey were
The major reasons of differences are unclear.

Hepatitis B birth dose and three vaccinations

8 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDRExecutive Summary

during infancy remain important preventive

strategies; therefore, careful monitoring andrepeated evaluation for national immunization
program are needed.

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 9

1. Introduction

1. Introduction

⿇⿇ Backgroundof Lao PDR. Therefore, population-based

infected with hepatitis B (HB) virus worldwide

understand the current situation and to evaluate

More than two billion people have beenand every year approximately one million
people die of HB virus infection, 33 % causedby hepatocellular carcinoma, and the rest with

sero-prevalence survey for HB is necessary to
the progress of immunization policy targeting
prevention for mother to child transmission [7, 8].

The Ministry of Health (MoH), Lao PDR andterminal complications of liver diseases [1, 2].

National Center for Global Health and Medicine

Organization (WHO) Western Pacific adopted theinvestigated. In January and February 2011, theThe Regional Committee for the World Healthresolution WPR/RC54.R3 in 2003 and resolution
WPR/RC56.R8 in 2005, calling for the reductionof chronic hepatitis B infection to less than
2% among 5-year-old children, as an interim

milestone towards the final regional goal of lessthan 1%, by 2012. Regional progress in hepatitis
B control strategies has resulted in a dramatic(NCGM) have agreed that sero-prevalence isteam focuses on central region of the country

as the pilot survey, and the whole country wascovered in January to February 2012.

Table 1. Hepatitis B vaccination activities
in Lao PDR

DTP-HepBDTP-HepB as routine
immunization

decline in hepatitis B infection among children,

2002

achieve the milestone (WPR/RC61/10).

2004

Birth dose introduced in Capital
hospitals

2005

2 southern province hospitals added

2007

8 more provincial hospitals added

2008

Remaining provincial and all 123
district hospitals added

and 27 countries and areas are expected to

Lao People’s Democratic Republic (Lao

PDR) has initiated its expanded programme on
immunization (EPI) in selected regions in 1984.
The program has scaled up to nationwide in

1994. Hepatitis B has included in EPI in 2002,

and gradually expanded (Table 1). Study fromneighboring countries, such as Cambodia, China,

Myanmar, Thailand, and Vietnam, revealed high

HB antigen prevalence [3, 4, 5, 6], but there

have been no previous reports of chronic HB

2009

Started Hepatitis B birth dose home
visits using health center workers
in 50 districts from 9 provinces

2010

Training of skilled birth attendants(SBA) who can work both in facilities
and attend births at homevirus infection rates among general population
10 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

1. Introduction

⿇⿇ Survey objectives

Primary objectives of the survey are;

1. To estimate hepatitis B surface antigen seroprevalence among children

2. To estimate hepatitis B surface antigen seroprevalence among mothers

3. To evaluate the potential risk factors

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 11

2. Methods

2. Methods

⿇⿇ Sample size calculation

program. When poverty reduction program’s list

measure of 1.96, margin of error of 0.02, expected

was used when survey team visits selected village.

Considering desired level of confidence

HBsAg positive rate of 0.05, design effect of 2.0,

with two strata, and response rate of 0.95, we

calculated required sample size of 961, which

was not available, EPI list, or relevant residents list
21 child and mother pairs were randomly selectedusing a paper-based lottery system.

Since questionnaire and blood collection

indicates 961 pairs of mothers and children (1,922

time is expected as 20 minutes per pair, andof children and mothers (2,016 individuals) arevillages, six pairs per day per survey team wereindividuals). For practical purposes, 1,008 pairs
planned to be collected.
⿇⿇ Sampling strategies

Stratified multi-stage random cluster

sampling was used to select pairs of children andmothers with child bearing age.

transportation is often difficult in and among

considered to be appropriate. Twenty four survey
teams were organized, and each team had two
surveyors.

⿇⿇ Data collection

Blood samples were taken by trained

Lao PDR comprises Vientiane capital andsurveyors using finger-prick method in selected

country includes 143 districts and more than

was used for taking blood. Approximately

16 administrative provinces in the country. The
10,000 villages according to census 2005. We
divided all districts into two strata in terms of

DPT-HepB3 (diphtheria, pertussis, tetanus, andvillages. Safety lancet® and glass capillary tube
50 micro liter of blood are needed to apply
Determine rapid test.

The survey included a brief questionnaire

hepatitis B third dose) immunization coverage;

to verify the participants’ sex, age and date of<76%). Twelve districts were randomly selectedcharacteristics, family history of hepatitis,high (72 districts >=76%) and low (71 districts

from each stratum, with applying probability
proportionate to size (PPS) sampling as the firststage. For the second stage, two villages werebirth, place of residence, sociodenographic
vaccination history, and potential risk factors ofgetting hepatitis B.

After pre-testing in a non-selected village,

randomly selected from each district by PPS.

two-day training session for supervisors andbased on residents list by poverty reduction

national advisors attended the session, too. The

In each of 48 villages, household list was madesurveyors was held just before the survey. The

12 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

2. Methods

lecturers were recruited from NIP and NCLE, MoH,
Lao PDR.

for this explanation, as more than 70% of mothers
would be illiterate in rural Lao PDR.

Participant information was remained

⿇⿇ HBsAg detection using Determine®

anonymous and confidential. Each participant has(Arlier, Japan). Briefly explaining, the blood apply

questionnaire and blood sample.

HBsAg was assayed using Determine®

onto the sample pad, followed by the chaseliquid. Fifteen minutes to 24 hours later, theresults can be read.

identification number, which is common between
The HBsAg results were informed tomothers on request. Survey teams consideredfollowing issues before giving results; 1) Viral

hepatitis is not curable in Lao PDR, 2) Determine®

⿇⿇ Data entry and analysis

All the information was input into theexcel file sheets. Data was validated by testing
double-entry checking.

The results were analyzed by STATA ver.

12.0 (Stata Corp., College Station, Tx, USA).
⿇⿇ Ethical considerations

is not used for individual diagnostic purposes, but

for epidemiological research, 3) HBsAg positive

persons may be discriminated by villagers
according to local beliefes, even survey teams
give detailed explanation about hepatitis B.
⿇⿇ Survey implementation

The hepatitis B survey was prepared,

To minimize risks, each blood sample

organized, executed and implemented at

Supervisors and surveyors were trained during

The steps involved in survey implementation arecollection used a new, disposable lancet.

training session. Surveyors followed manufacturer
instructions and used a pair of latex gloves foreach child. Immediately after use, all lancets andcotton balls were placed in safety boxes.

national, provincial, district, and village levels.
summarized as follows.
⿇⿇ Ethical approval

NIP, NCLE, and NCGM had discussion of

Before conducting the survey, local

rationale, methodology, necessary information,of local Women’s Union) and the parents or

survey with assistance from WHO (WPRO andauthorities (village leaders and the presidents
guardians of selected children received oral andwritten information. Special attention was paid

funding, and human resources required for the
Lao PDR) offices. The study group developed

the survey protocol and submitted to ethicalTechnical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 13

2. Methods

committees in MoH, Lao PDR and in NCGM, Japan.

The ethical committee in MoH, Lao PDR approved
the survey protocol in January 20, 2011, and themade combined list of residents, and followed
the same selection process.

NCGM ethical committee approved the survey in

⿇⿇ Training supervisors and surveyors(NCGM-G-001130-00).

advisors (six from NIP and five from NCLE), 13

⿇⿇ Official request letter to survey sites andfield. The surveyors’ background were mainly

January 6, 2011 (NCGM-950) and January 10, 2012

collecting lists of eligible subjects

After selection of villages, the MoH

cabinet sent an official letter to the relevant
provinces, districts and villages. Complete listsof the residents were not available beforehand,
therefore, selection using paper-based lottery
system was considered.

⿇⿇ Survey subjects selection

Based on the lists provided by eachvillage, NIP staff randomly selected 21 children

for participation. Child and mother pairs wererandomly selected using a paper-based lottery

The study team recruited 11 national

provincial supervisors, and 48 surveyors in thelaboratory and epidemiology staff. National

advisors supervised one or two provinces, andresponded to clarifications and questions fromthe surveyors.

Two-day training for both supervisorand surveyor provided finger-prick using safety

lancet, blood collection and Determine® result

reading, and taking questionnaire. The training
also included national policy against hepatitis B,

coding system, ethical issues, and confidentiality.
To ensure random selection in villages, using apaper-made lottery sysytem was emphasized.

system in which 21 rectangular strips of paper,

⿇⿇ Preparing materials

250, were randomly drawn from an envelope

prepared the coding system for each participant.

team had one envelope containing 250 strips of

district number-village name) and a personalmeasuring 20 x 2 cm and numbered from 1 toto select 21 child and mother pairs. Each survey
paper.

When a selected village lacked sufficientnumber of children, the survey team selected thenearest village on the way back to district center,

Before conducting the survey, NIP staff

Coding included a cluster code (province numbercode (two digits ranging from 01 to 21 plus ‘C’for children and ‘M’ for their mothers). Eachcode was written on the questionnaire sheets,
and Determine® rapid test. All survey materials

14 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

2. Methods

specific to each cluster were packaged together
with. Each survey team received these packagesof materials before departing to survey sites.
⿇⿇ Conducting serology in the field

After the blood taking and questionnaire, asmall gift was handed (a packet of confectionary,stationery materials, and so on), and hard candy

was avoided, as participants’ younger sibrings
may have possibility of suffocation. At the end ofeach day, the supervisors and surveyors verified
the questionnaire and blood test results.

The data collection was carried out

from January 25th to February 4th excludingtransportation time, and completed within two

weeks. Data input was conducted in Lao PDR andin Japan.

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 15

3. Results

3. Results

The survey teams successfully visited all

48 selected villages except one village, which
could not be approached because of difficultroad condition. An alternative village was chosen

and four were less than 15 years of age. A totalof 965 pairs were included for the prevalencecalculation.

Seventeen out of 965 children (1.8%) andaccording to predetermined selection criteria.

28 out of 965 mothers (2.9%) showed positive forsampled 1,008 children and 1,008 their mothers.

prevalence among children and their mothers

Data collection was successfully carried out andThe overall response rate was 100%; however,

43 pairs were excluded from the analysis due toage ineligibility. That is, four children were over 9

years of age and 30 were less than 5 years of age.
Moreover, five mothers were over 45 years of age

HBsAg. The table below shows the overall HBsAg
after taking the sampling design and samplingweight for each individual into account. HBsAg

prevalence in each age gourp by strata (high andlow DPT-HepB 3 coverage) is also presented.

HBsAg prevalence among children (five to nine year-old) and their mothers (15 to45 years-old)
Table. National HBsAg prevalence among children and their mothers
Ages
Children(n=965)
Mothers(n=965)

HBsAg prevalence

95% C.I.

Design effect1.7%

0.8-2.6%

1.1

2.9%

1.7-4.2%

1.3

16 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

3. Results

Table. HBsAg prevalence among children and their mothers by DPT-HepB 3 coverage
Ages
Children, low coverage(n=479)Children, high coverage(n=486)

HBsAg positive rate

95% C.I.

2.3%

1.0-3.6

1.2%

0.2-2.2

1.9

0.7-3.1

3.7

2.0-5.4

Mothers, low coverage(n=479)Mothers, high coverage(n=486)

Table . HBsAg distribution by background characteristics
Factors

Children

Value
<=19

Mother's age

Transportation to thenearest health facility

HBsAg
positive

HBsAg
negative

HBsAg
positive

85

1

82

3

266

9

0

4

25-29

294

7

286

35-39

176

3

173

30-34

275

40-45

Ethnicity

HBsAg
negative
4

20-24

Mothers

Lowland Lao
Midland Lao

Highland Lao

131

0

3

4

9

632

19

62

2

61

3

242
297

Bike

357

14

6

5

292

7

354

10

3

62

4

0

178

5

Others

14

0

63

243

1

Car

Tractor

127

8

642

Walk

Bicycle

6

0

14

177
14

6

0
6

0

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 17

3. Results

Factors

Value

health facility(min)HBsAg
positive

HBsAg
negative

HBsAg
positive

5-14

271

3

268

6

30-59

204

5

205

15-29

60-480Mother’s educationleveloccupation

operation
Child's sex

220

11
4

Primary school
not finished

300

7

295

12

Primary school
finished

369

5

364

10

Junior high school
finished

182

3

183

2

High school
finished

73

0

72

1

College or university
finished

19

1

18

2

Farmer

670

13

664

19

Labour

91

1

87

5

Factory employee

8

0

8

0

63

0

Public officer

587

General Employer

15

Others

8

Yes

62

93

0

1

0

8

1

2

15

Female465

9Health center
Private clinic

479

203

103
10

11

House

561

Others(facility)

3

Yes
No

53
22

922

18 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

85
16

852

Male

5

1

No

In bushoperation

1

4

District hospitalChild’s surgical

5

30

152

Province hospital

Place of delivery

226

0

3

Merchant

Mother’s surgical

31

153

Fisherman
Family head

Mothers

HBsAg
negative

0-4Time to the nearest

Children

93

0

3
0
0

3

843

24

4

201

6

0

10

0

7

2
0

100
10

5

1

8

555

14

0

3

0

3
0

16

55

1

4. Disucussion and Recommendations

4. Discussion and Recommendations

⿇⿇ Discussion

behavioral differences may contribute to the

1. Implementation of the survey

HBsAg sero-prevalence survey was

lower prevalence.

2) The majority of the previous surveys did

successfully completed because of variety of

not adequately represent the entire population

1) The MoH, Lao PDR strongly committed to(blood donors [9] and the hospitalized patients

reasons.

conduct the survey.

2) Communication and coordination was wellestablished in all levels of work.

3) Local authorities and health volunteers arewell involved.

4) Survey team was very well prepared, because

they learned a lot from the pilot study
targeting central region of the country in2011.

2. HBsAg prevalence among children and theirmothers in child bearing ages

The estimated HBsAg prevalence of thegeneral population was much lower in bothchildren and adults than that of previous reports
from neighboring countries and Lao PDR [3, 4, 5,
6]. There are several potential explanations forthese observations.

1) Lao PDR’s population density is lower

than that of surrounding countries, and thus,

human contact is less frequent. Additionally,
road, railway, aviation, and related infrastructure

are less developed in Lao PDR, and thus, thereis less chance for spread of viruses. Cultural, andof the country. For example, previous two studies[10]) revealed high prevalence of hepatitis B in

urban areas of Lao PDR, however, the sampledindividuals did not represent the general
population.

3. Potential risk factors

The survey revealed that no potential risk

factors were significantly associated with thechildren’s infection status, with the exceptionof the mothers’ hepatitis B infection status.
Previous HBsAg prevalence studieys revealed
that toothbrush sharing, history of surgery,level of mother’s education, and ethnicity
were independently associated with hepatitis

B infection [11, 12, 13, 14]. The reason why we
could not find any potential risk factors having
a positive association with hepatitis B infection
among children is not clear, but may be due tothe small number of positive cases. However, it

should be noted that the primary objective of thepresent study was to assess HBsAg prevalence,and not its risk factors. Additionally, some reports

found that HIV positive individuals are positively
associated with hepatitis B virus infection;

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 19

4. Discussion and Recommendations

however, we did not investigate HIV due tolimited budget.

4. WHO’s regional target

The interim target of the WHO is to reducedata.
2. When conducting the next survey, we

recommend that the target population
include;HBsAg prevalence to less than 2% in children

1) mothers, because they are the source of

R8). The point prevalence is used for monitoring

2) 2) fathers, because they may be the source

aged at least 5 years old by 2012 (WPR/RC56.

the control of hepatitis B. Following thesecriteria, Lao PDR had already achieved its goal

vertical transmissionof horizontal transmission of hepatitis B
virus to children[7, 8]. However, it is unlikely that Lao PDR had

3) marginalized population, such as floating

program alone because the country has the

because they are often not registered, andachieved the target through the immunization

lowest immunization coverage of all countries
in the region. Considering the relatively lower

HBsAg seroprevalence among the mothers

compare to those reported in previous studies
suggests that the country has a lower prevalence

immigrants or commercial sex workers,
may have higher prevalence of hepatitis B

than general population. Special attention

should be paid to collect data from them,such as oversampling methodology.

even before the introduction of the hepatitis B
immunization program. Therefore, the final targetof reducing HBsAg prevalence to less than 1% inchildren aged at least 5 years could be difficult toachieve if the country simply continues its current
immunization policy.

⿇⿇ Recommendations

1. T o e v a l u a t e t h e p r o g r e s s o f n a t i o n a limmunization programs, the HBsAg
prevalence survey should be repeated. The
next survey should utilize the latest census

20 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

References

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7. Rani M, Yang BP, Nesbit R (2009) Hepatitis B control by 2012 in the WHO
Western Pacific Region: rationale and implications. WHO Bull 87: 707-713.
8. World Health Organization (2011) Progress towards meeting the 2012
hepatitis B control milestone: WHO Western Pacific Region, 2011. Wkly
Epidemiol Rec 86: 180-188.
9. Jutavijittum P, Yousukh A, Samountry B, Samountry K, Ounavong A, et al.
(2007) Seroprevalence of hepatitis B and C virus infections among Lao blood
donors. Southeast Asian J Trop Med Public Health 38: 674-679.
10. Syhavong B, Rasachack B, Smythe L, Rolain JM, Roque-Afonso AM, et al. (2010)
The infective causes of hepatitis and jaundice amongst hospitalised patients in
Vientiane, Laos. Trans R Soc Trop Med Hyg 104: 475-483.

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 21

References

11. Soeung SC, Rani M, Huong V, Sarath S, Kimly C, et al (2009) Results fromnationwide hepatitis B serosurvey in Cambodia using simple and rapid
laboratory test: implications for national immunization program. Am J Trop Med
Hyg 81: 252-257.
12. Duong TH, Nguyen PH, Henley K, Peters M (2009) Risk factors for hepatitis B
infection in rural Vietnam. Asian Pacific J Cancer Prev 10: 97-102.
13. Ashraf H, Alam NH, Rothermundt C, Brooks A, Bardhan P, et al. (2010)
Prevalence and risk factors of hepatitis B and C virus infections in an
impoverished urban community in Dhaka, Bangladesh. BMC Infect Dis 10: 208.
14. Liang XF, Bi SL, Yang WZ, Wang LD, Cui G, et al (2009) Epidemiologicalserosurvey of hepatitis B in China-declining HBV prevalence due to hepatitis B
vaccination. Vaccine 27: 6550-6557.

22 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDRAnnexes

Annex 1: Selected districts and villages
Annex 2: Questionnaire
Annex 3: Informed Consent form
Annex 4: Training agenda
Annex 5: Supervisors and surveyors
Annex 6: Publication with PLOS ONE

Annex 1: Selected Districts and villages for the survey

Selected Districts and villages- Selected districts and villages

Xay:• Nalao• NamkoudHouixay:

Viengthong:• Danthin• Manth• Saychalurn• Houaisou

Xiengkhor:• Nahuea• Hub

Phaoudom:• Hartli• Homesook

Hongsa:Pek:• Naphoung• Phonhthong• Namsib• Phonhsavanhsay

Luangprabang:• Khouaty 1• YangAtsapangtong:• Nalaydong

Kenethao:Toulakhom:• Chomkeo• Kangmeuang• Pakkham

Xanakhame:

Sikhottabong:• Vanghueang• Nonkeo• Sithannuea• Siphoun• Xaysomboun

Nong:• Tayong

Xaythany:• Saen-Koh• Phoukham• Tha dean deng nuea

• Nasack

Toumlane:Champhone:
Chanthabouly:• Phontong chommany nuea

• Hatsadee tay• Nahonggnai• Laosouliya• Donekhagnungna• Luck 35

Xonbuly:

Saravane:• Houaimuang• Baengxekong• Tangvaitay• Nongbouagnai

Phonthong:• Phonkeo• PongSukhuma:• Hae• Nong phan vong

24 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

Bachieng:• Nongboknoy

Khong:• Bounnoy• Dedvanttok• Huoaisae

Annex 2 : Questionnaire

Questionnaire for mother and child to evaluate the result of giving service forpreventing the spread of Hepatitis B//
Date (D/M/Y)

Questionnaire ID

Interviewer

Remarks: The objective of this questionnaire is to collect the information on improving
health care services giving to mother and child for prevention of Hepatitis B. This isconfidential, so we will not record your name. This questionnaire will be destroyed
after data entry into the computor. To investigate the information, please answer
correctly acccording to your knowledge.
I. General information (for mother*)*age 15-45 years old
No.
Q101

questionanswercode

remarkvillage
districtprovince

Address
Q102 Date of birth and age (mother)

Q103 Ethnicity:

Q104 Do you use vehicle when you
go to the nearest healthfacility? (provincial hospital,
district hospital, clinic, healthcenter). If yes, what kind ofvehicle do you use?

(D/M/Y)____/____/____
years old(select only one)
1. Lowland lao
2. Midland lao
3. Highland lao(Select only one)
1. walk
2. bicycle
3. motor bike
4. car
5. hand tracter
6. others:
specify_____________

Q105 How long does it take to thenearest health facility?
______/______
hours / minutes
Q106 Which level did you finish your (Select only one)study? (for mother)
1. no education
2. finished primary school
3. finished junior highschool
4. finished high school
5.
finished
college/university
6. others
specify_____________

[

]

[

]

[

]

[

]

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

125

Annex 2 : Questionnaire

Questionnaire ID
Q107

Q108

Q109

Q110

Q111

What is the occupation of the (Select only one)head of the family ?
1. farmer (dry field or
paddy)
2. fisherman
3. labor
4. public officer
5. factory employee
6. general employer
7. merchant
8. others
specify ___________Have you ever received blood (Select only one)transfusion?
1. yes
2. no
3. do not know
How many times have you 1. never
had surgical operation?
2. once(including minor surgery, 3. twice or morecesarean section, etc)
4. do not know
Is there anyone in your family
who has liver disease or died 1. none
from liver disease?
2. I have
3. Husband has or died
(ex:jaundice of eye and body) from a liver disease
4. parent has or died from aliver disease
5. brother or sister has ordied from a liver disease
6. do not know
How many children do you
Number of children
have?
[
]

26 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

2

[

]

[

]

[

]

Yes=1, No=0
[
]
[
]
[
]
[

]

[

]

[

]

[

]

Annex 2 : Questionnaire

Questionnaire ID
I. Questions for a child
Choose the youngest child in the group of age between 5 to 9 years oldNo.
question
Q201 Date of birth and age (child)answer
(D/M/Y)____/____/____/
years old
Q202 Sex of the child(Select one)
1. male2. female
Q203 Where was this child born? (Select only one)
1. provincial hospital
2. district hospital
3. health center
4. private clinic
5. house
6. in bush near house
7. other place
specify: __________
Q204 Why did you select the (Choose all it apply)
place to give birth?
1. feel safe
2. more convinient
3. more economical
4. family suggested
5. traditional birth attendantsuggested
6. health center or hospital
staff suggested
7. could not go to thehospital because the childwas born too quickly
8. that has been the customof the community
9. others
specify _____________

code

remark[][]Yes=1, No=0
[
]
[
]
[
]
[
]
[
]
[

]

[

]

[

]

[

]

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

327

Annex 2 : Questionnaire

Questionnaire ID
Q205 Who attended or helped the (Choose all it apply)
delivery of this baby?
1. medical staff
2. village health volunteer
3. TBA
4. family member
5. no one
6. others
specify _____________
Q206 Where did your child (Select only one)recieve vaccination?
1. hospital
2. health center
3. in the village with medical
staff
4. private doctor
5. did not recieve
6. do not remember
7. others
specify _____________
Q207 How do you know about (Choose all it apply)
vaccine? Through what 1. medical staff told you
media or people do you get 2. it is wirtten on theinformation about vaccine?
vaccination note
3. brothers/sisters or friend
told you
4. Radio / TV
5. local authority told you
6.others
specify ___________
7. do not know
Q208 Has the child ever received (Select only one)blood transfusion?
1. yes
2. never3. do not know
Q209 How many times has the (Select only one)
child
had
surgical 1. neveroperation?
2. once
3. twice or more
4. don’t know
Q210 Has the child ever shared (Select only one)
toothbrushwithfamily 1. yes, often
members?
2. yes, sometimes
3. yes, but very rare
4. never5. don’t know
28 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

4

Yes=1, No=0
[
]
[
]
[
]
[
]
[
]
[
]

[

]

Yes=1, No=0
[
]
[
]
[

]

[
[
[

]
]
]

[

]

[

]

[

]

[

]

Annex 2 : Questionnaire

Questionnaire ID
II.Other information related to immunization
No.
question
Q301 Do you have vaccination card(yellow) or mother and childhandbook? (for the child who
was surveyed)

Q302 Usually who is the one todecideabout
givingvaccination?

Q303 How do you know the datethat health center staffs cometo give vaccination?

answer(Select only one)
1. have both
2. have only yellow
card
3. have only motherand child handbook
4. have neither(Select only one)
1. father
2. mother (yourself)
3.grandfather/
grandmother4. village leader
5. others
Specify______(Choose all it apply)
1. village leader
2.
villagehealthvolunteer
3. woman’s union
4. megaphone5.
advertisement
poster
6. health center staff
7. official letter fromthe district governer
8. others
specify ______

code

remark[][]Yes=1, No=0
[
]
[
]
[
[
[

]
]
]

[
[

]
]

[

]

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR
529

Annex 2 : Questionnaire

Check the child’s Yellow Card, and record the dates of immunization below:
1.

2.

3.

4.

5.

BCG

Hep B

0 – 11 months

0 – 24 hours…………/…..…/…………
D/M/Y…………/…..…/…………
D/M/Y

DPT-Hep B1

Polio1Minimum 6 weeks from 1

Minimum 6 weeks from 1…………/…..…/…………
D/M/Y…………/…..…/…………
D/M/Y

DPT-Hep B2

Polio2

1 month after DPT-HepB1

1 month after Polio1…………/…..…/…………
D/M/Y…………/…..…/…………
D/M/Y

DPT-Hep B3

Polio3

1 month after DPT-HepB2

1 month after Polio2…………/…..…/…………
D/M/Y…………/…..…/…………
D/M/Y
9 – 11 months

Measles…………/…..…/…………
D/M/Y
12 – 23 months…………/…..…/…………
D/M/Y
Record Determine results (Read Instruction carefully. Repeat test when ‘Invalid’)
Determine test results
MotherChild

remarkcode

1. positive
2. negative
3. not done
1. positive
2. negative
3. not done

Control Bar

Control Bar

Control Bar

Control Bar

Patient Bar

Patient Bar

Patient Bar

Patient Bar

Positive

Negative

Invalid
630 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

Invalid

[

]

[

]

Annex 3 : Informed Concent form

<Informed consent form for parents>
Dear parent,

1. Introduction
This research is conducted by Mother and Child Health Center, Ministry of Public Health, Lao
PDR, in collaboration and agreement with NCGM (National Center for Global Health andMedicine).

2. Purpose of this research
Hepatitis B is caused by a virus called hepatitis B virus. If a virus stays in your body for a long period,
virus can cause liver diseases later on. It seems that there are many people with this virus in Laos
(possibly one person per 5-6 persons). It is important to prevent this virus to enter your body since itis difficult to treat once you get infected. Most people with this virus are considered to get infectedfrom their mothers when they were born. You can avoid this disease for 95% if you get vaccinatedimmediately after you were born. Ministry of Health, Lao PDR has already started a vaccination
programme to prevent mother to child transmission of this virus.
Ministry of Health needs information how many mothers and children have this virus in order toutilise this information to improve this programme in the future.

3. Participant selection of this research
We are inviting children (5-9 years of age) and their mothers (15-45 years of age).

4. Method of this research
We take a blood sample from your fingertip by using a safety lancet. We draw your blood from asmall wound in your fingertip and put it on a diagnostic kit and a filter paper. The amount of blood weneed is approximately between 0.05mL and 02 mL. All the blood taking process is done by atechnician who has been trained for this research. They put a clean tape on your wound to prevent
germs to get inside afterwards. We use a new safety lancet needle for each individual.

5. Confidentiality
We will ensure that your information and your child’s information are kept safe and anonymously.
No one except the staff involved in this research will have access to information.

6. Right to refuse or withdraw

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

31

Annex 3 : Informed Consent form

Your participation in this research is entirely voluntary. It is your choice whether to participate or not.
Refusing to participate will not give you any disadvantage. You may stop participating in the
research at any time you wish. Stop to participate will not give you any disadvantage either.

The above is information about this research and we inviting you to be a part of this research.
Please contact any of the members of staff if you have any further questions or queries.

The person in charge of the study

Annoh Xeuatvongsa MD, PhD

Masahiko Hachiya, MD, PhD, MPH

Director

Staff, Expert Service Division

Department

ofExpanded

Programon

Department of International Medical

Immunization (EPI)

Cooperation

Mother and Child Health Center

National Center for Global health andMinistry of Public Health, Lao PDR

Medicine (NCGM)
1-21-1 Toyama, Shinjuku, Tokyo,
162-8655, JAPAN
Tel; +81-3-3202-7181,
Fax; +81-3-3205-7860
E-mail; m-hachiya@it.ncgm.go.jp

32 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDRAnnex 3 : Informed Concent form

<Informed consent for parents>

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions I have been asked have been answered to my satisfaction. I
consent voluntarily to be a participant in this study and understand that I have the right to withdraw
from the study at any time without in any way affecting my medical care.

Print name of participantSignature of participant

Date( Day/Month/Year)__________________________________________________________

If illiterate
A literate witness must sign (if possible, this person should be selected by the participant andshould have no connection to the research team). Participant who is illiterate should include theirthumb print as well.

I have witnessed the accurate reading of the consent form to the potential participant, and theindividual has had the opportunity to ask questions. I confirm that the individual has given consent
freely.

Print name of participantSignature of participant

Date( Day/Month/Year)__________________________________________________________

I have accurately read or witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I confirm that the individual
has given consent freely.

Print name of participantSignature of participant

Date( Day/Month/Year)__________________________________________________________

A copy of this informed consent form has been provided to the participant

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

33

Annex 4 : Training agenda

Training agenda 2012
23rd Jan
08:00

Registration

08:30

Opening

Dr. Phengta, Dr. Hachiya

09:00-10:00

Purpose of WS

Dr. Anonh

10:00-10:15

Break

10:15-10:30

Study design

Dr. Hachiya, Dr. Anonh

10:30-12:00

Household listing

Dr. Tongchanh(Lecture and practice)
12:00-13:30

Lunch

13:30-15:00

Questionnaire

Dr. Tongchanh(Lecture and practice)
15:00-15:15

Break

15:15-16:15

TOR of surveyors, supervisors, advisors

16:15-16:30

Q&A

Dr. Phengta, Dr. Anonh

24th Jan
08:30-10:30

Blood sampling

Dr. Tongchanh(Lecture and practice)
10:30-10:40

Break

10:40-11:20

Ethical consideration

Dr Anonh

11:20-12:00

Writing the identification numbers

Dr Anonh(Items; questionnaires)
Reporting using SMS and collecting data

Dr Anonh(Lecture and practice)
12:00-13:00

Financial and logistic issues

13:00

Closing

34 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

Dr Phengta, Dr Hachiya

Annex 5: Supervisors and surveyors

NumberName

Roles during Survey

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56

Ms. Vilaphenh Yengmala
Ms. Kham Taune Kouangvanh
Ms. Bounteing Phommavongsa
Mr. Khamsen Phanouvong
Ms. Sengphet Douangsavay
Pengthong Keomahavong
Ms. Lamthong Pamisay
Mr. Houmpheng Thionkeo
PhonepaseuthThongkham Keobouachanh
Ms. Ketchanh Sysavath
Mr. Khamsim
Ms. Souchitta Heuanmisavath
Mr. Bounleune SitdavanhThongphet
Mr. Phanthaly
Ms. Somdy
Ms. Manisouk Phonpadid
Mr. Aiew Thong
Mr. Phanthong Souvannaly
Mr. Bountienne Souphanthong
Ms. Pom Keohomdy
Mr. Khamphanh Keobounta
Ms. Siamphone Vannithorn
Mr. Touk Souvannasing
Dr. Souvanxay Phetthanaxay
Mr. Thongdy Phouangkeo
Mr. Songkharm Masouvanh
Ms. Somsanith Ounthavong
Mr. Thoumphone Bounlieng
Ms. Khamla Yoysaykhem
Mr. Khounlavanh Keolakotphosy
Ms. Manisong Vikayhong
Ms. Bounvang Phinith
Mr. Sisouphan Davanh
Ms. Bouasone Vilailoth
Ms. Orlathay Phongphoun
Mr. Inpeng Nanthanontry
Mr. Salika Kietsatit
Mr. Khampha Senviseth
Ms. Phoukhao
Ms. Sypaseulk
Ms. Bounthan Souvannavong
Ms. Bounta Xayavong
Dr. Laycham Chamsina
Dr. Viengsayphone Mylounsa
Ms. Souphalack Keoounheuane
Dad Samkham
Mr. Sengdavy Syonesa
Mr. Vilayvong
Ms. Viengsavanh Phimpiseng
Mr. Khamla Souphavady
Mr. Visay Xounthay
Ms. Khaysy Vonvilay
Ms. Phimmasone Duangvilay
Mr. Maly Thoubthong

Vientiane C Supervisor
Vientiane C Surveyor
Vientiane C Surveyor
Vientiane C Surveyor
Vientiane C Surveyor
Vientiane C Surveyor
Vientiane C Surveyor
Oudomxay Supervisor
Oudomxay Surveyor
Oudomxay Surveyor
Bokeo Supervisor
Bokeo Surveyor
Bokeo Surveyor
Bokeo Surveyor
Bokeo Surveyor
Luangprabang Supervisor
Luangprabang Surveyor
Luangprabang Surveyor
Huaphan Supervisor
Huaphan Surveyor
Huaphan Surveyor
Huaphan Surveyor
Huaphan Surveyor
Xayabouly Supervisor
Xayabouly Surveyor
Xayabouly Surveyor
Xayabouly Surveyor
Xayabouly Surveyor
Xiengkuang Supervisor
Xiengkuang Surveyor
Xiengkuang Surveyor
Vientiane P Supervisor
Vientiane P Surveyor
Vientiane P Surveyor
Vientiane P Surveyor
Vientiane P Surveyor
Savannakhet Supervisor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Savannakhet Surveyor
Saravane Supervisor
Saravane Surveyor
Saravane Surveyor
Saravane Surveyor
Saravane Surveyor
Champasak Supervisor
Champasak Surveyor
Champasak Surveyor
Champasak Surveyor
Champasak Surveyor
Champasak Surveyor

Position
Technical Officer
Epidemiology
Deputy Chief of Labo.
Epidemiology
Laboratory
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Surveillance staff
Surveillance staff
Epidemiology
Laboratory
Laboratory
Epidemiology
Laboratory
Epidemiology
Laboratory
Epidemiology
Surveillance staff
Surveillance staff
Laboratory
Epidemiology
Epidemiology
Laboratory
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Laboratory
Epidemiology
Laboratory
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Epidemiology
Epidemiology
Laboratory
Epidemiology
Epidemiology
Epidemiology
Epidemiology
Laboratory
Epidemiology

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

35

Annex 5: Supervisors and surveyors

Number
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78

Name

Roles during Survey

Position

Ms. Saovalith SimeuangChampasak Surveyor
Laboratory
Ms. Phaiboun Chansavad
Champasak Surveyor
Laboratory
Ms. Manivone BouathongChampasak Surveyor
Laboratory
Dr. Darouny Phonekeo
Vientiane C National Advisor NCLE staff
Dr. Anonh
Oudomxay National Advisor
EPI Director
Dr. Khansay Sengsaya
Bokeo National Advisor
NCLE staff
Dr. Virasack Somoulay
Luangprabang National Advisor NCLE staff
Dr. Khamphet Louanglat
Hoaphan National Advisor
EPI staff
Dr. Khongxay
Xayabuly National Advisor
EPI staff
Dr. Souphatsone Houathougkham Xiengkuang National Advisor NCLE staff
Dr. Dasavanh Manivong
Vientiane P National Advisor MCH staff
Dr. Chansay Pathammavong
Savannakhet National Advisor EPI staff
Dr. Chanthavy Soulaphy
Saravane National Advisor
NCLE staff
Dr. Somvang BouphaphanhChampasak National Advisor EPI staff
Dr. Phengta Vongphrachanh
Lecturer
NCLE Director
Dr. Bounthanom Sengkeopraseuth Lecturer
NCLE staff
Mr. Khamphet
Driver
EPI staff
Mr. Bouavanh Boualivanh
Accounting
EPI staff
Ms. Bounsalong Xayasinh
Accounting
EPI staff
Ms. Bounphet Sisoumang
Accounting
EPI staff
Ms. Phailamphanh Manivong
Vientiane P National Advisor Epidemiology
Ms. Vilaphanh Yengmala
Savannakhet National Advisor Surveillance staff

36 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDRAnnex 6: Published article

Chronic Hepatitis B Prevalence among Children andMothers: Results from a Nationwide, Population-Based
Survey in Lao People’s Democratic Republic
Anonh Xeuatvongsa1, Kenichi Komada2, Tomomi Kitamura2, Phengta Vongphrachanh3,
Chansay Pathammavong1, Kongxay Phounphenghak1, Thongchanh Sisouk3, Darouny Phonekeo3,
Bounthanom Sengkeopaseuth3, Vilasak Som-Oulay3, Koji Ishii4, Takaji Wakita4, Masaya Sugiyama5,Masahiko Hachiya2*
1 National Immunization Program, Ministry of Health, Lao PDR, Simeuang Road, Vientiane, Lao PDR, 2 Bureau of International Cooperation, National Center for Global
Health and Medicine, Shinjuku, Tokyo, Japan, 3 National Center for Laboratory and Epidemiology, Ministry of Health, Lao PDR, Simeuang Road, Vientiane, Lao PDR,
4 Department of Virology II, National Institute of Infectious Diseases, Musashi-murayama, Tokyo, Japan, 5 Hepatology Research Center, National Center for Global Healthand Medicine, Ichikawa, Chiba, Japan

Abstract
Background: Hepatitis B is regarded as a serious public health issue in Lao People’s Democratic Republic (Lao PDR), a
Southeast Asian country. However, disease epidemiology among the general population is not well known, and thus anationwide cross-sectional survey for hepatitis B surface antigen (HBsAg) prevalence in children and their mothers was
conducted.
Methods and findings: We applied three-stage cluster sampling using probability proportionate to size. After randomly
selecting child (5 to 9 years old) and mother (15 to 45 years old) pairs from the selected villages, questionnaires and HBsAg
rapid tests were conducted. Data from 965 child and mother pairs were analyzed. Multivariate logistic regression analyses
were used to investigate the independent association of individual background characteristics for the odds of being HBsAg
positive. In total, 17 children and 27 mothers were HBsAg positive. HBsAg prevalence was estimated to be 1.7% (95%
confidence interval: 0.8%-2.6%) in children, and 2.9% (95% confidence interval: 1.7%–4.2%) in their mothers after taking
sampling design and weight of each sample into account. Mother’s infection status was positively associated with HBsAg
positivity in children (p,0.001), whereas other potential risk factors, such as ethnicity, proximity to health centers, andhistory of surgery, were not. There were no significant associations between mother’s HBsAg status and history of surgery,and other sociodemographic factors.
Conclusions: Despite the slow implementation of the hepatitis B vaccination program, HBsAg prevalence among children
and their mothers was not high in Lao PDR compared to reports from neighboring countries. The reasons for the differencesin prevalence among these countries are unclear. We recommend that prevalence surveys be conducted in populations
born before and after the implementation of a hepatitis B vaccination program to better understand the epidemiology ofhepatitis B.
Citation: Xeuatvongsa A, Komada K, Kitamura T, Vongphrachanh P, Pathammavong C, et al. (2014) Chronic Hepatitis B Prevalence among Children and Mothers:
Results from a Nationwide, Population-Based Survey in Lao People’s Democratic Republic. PLoS ONE 9(2): e88829. doi:10.1371/journal.pone.0088829
Editor: Pierre Roques, CEA, France
Received October 28, 2013; Accepted January 13, 2014; Published February 28, 2014
Copyright:  2014 Xeuatvongsa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by The Grant for Nationa Center for Global Health and Medicine (25-8). The funders had no role in study design, datacollection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: m-hachiya@it.ncgm.go.jp

agent to humans by the International Agency for Research on
Cancer [5].
The prevalence of hepatitis B differs throughout the world.
Southeast Asian countries have been estimated to have a chronic
HBV infection rate of more than 8% before the introduction ofhepatitis B vaccination [6]. The Western Pacific region of theWorld Health Organization (WHO), to which most of theSoutheast Asian countries belong, is assumed to have a highprevalence of hepatitis B [7]. Specifically, the prevalence isestimated to be 9% to 12% among women of childbearing age [8]and 8% to 10% among children in pre-vaccine era [9]. The WHO

IntroductionMore than two billion people have been infected with hepatitis
B worldwide, and among these individuals, more than 350 million
suffer from chronic hepatitis B virus (HBV) infection [1,2,3].
Infection with HBV results in 600,000 to 1.2 million deaths per
year due to chronic hepatitis, cirrhosis, and hepatocellular
carcinoma [2,4]. HBV is responsible for 60% to 80% of theworld’s hepatocellular carcinoma cases, one of the major threecauses of death in Africa, Asia, and the Pacific Rim, andaccordingly, has been categorized as a Group 1 carcinogenic

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Annex 6: Published articles

Hepatitis B Prevalence in Child and Mother Pairs

estimates that the region has 28% of the global population, while itaccounts for almost half of all chronic hepatitis B infections
worldwide [10].
Hepatitis B vaccination, especially within 24 hours afterchildbirth, is considered the most effective and efficient preventive
measure against hepatitis B infection [3,11]. Based on theseassumptions, the WHO set goals to lower the prevalence ofchronic hepatitis B among children over 5 years of age to 2% by2012 and 1% by 2017. To achieve these goals, the WHO plans toincrease immunization coverage to 65% for the birth dose and
80% for the third dose of the hepatitis B vaccine [7].
Lao People’s Democratic Republic (Lao PDR) is a Southeast
Asian country, located in the center of the Indochina peninsula.
The country is landlocked and surrounded by China, Vietnam,
Cambodia, Thailand, and Myanmar. The neighboring countries
report relatively high hepatitis B prevalence compared to otherparts of the world. For example, a survey from two provinces in
Cambodia reported a hepatitis B surface antigen (HBsAg)
prevalence of 7.7% (95% CI: 6.2%–9.3%) among healthy
volunteer adults [12]. Another population-based survey in aprovince in rural Vietnam found that 18.8% (95% CI: 15.7%–
21.9%) of adults and 12.5% (95% CI: 9.7%–15.3%) of infants
were HBsAg positive at the time of the survey [13]. Thus, Lao
PDR has been regarded as one of the hyperendemic countries forhepatitis B for quite some time and is ranked as a priority country
by the WHO [7,9] despite a lack of data on the prevalence in a
representative population. Pre-vaccine era prevalence was estimated as 11.8% [4], 8–10% [9], or 8% or more [6] for Lao PDR
and Indochina countries. In response to this situation, Lao PDR
has implemented the hepatitis B vaccine into the routine
immunization program since 2002 (at 6, 10, and 14 weeks after
birth), as well as birth dosing since 2004. The birth dosing was
initiated at referral hospitals in the capital city, and then gradually
expanded into rural hospitals (2006), and eventually homedeliveries (2010). However, since then, no direct investigation
has been conducted, and thus a nationwide survey is warranted[7,9]. The routine immunization coverage is reported as 56% for
BCG, 50% for the third DPT, 50% for the third hepatitis B, 40%
for measles, and 46% for oral polio vaccine in 2007, when aproportion of target children were born [14].
The primary objective of the present study was to estimate thechronic HBV infection rates by measuring the seroprevalence of
HBsAg among children aged 5 to 9 years, and their mothers aged
15 to 45 years.

mothers were illiterate. The respondents’ names were not recordedon the questionnaire sheets.

Study population
The target population was children aged 5 to 9 years (date ofbirth: January 2, 2002 to January 1, 2007) and their mothers aged
15 to 45 years (date of birth: January 2, 1966 to January 1, 1997)
living in the selected cluster at the time of the survey. The reasonsfor this selection criteria are: 1) the national and regional hepatitis
control policy target is to reduce chronic hepatitis B prevalence
among children aged 5 years or older [7]; 2) Lao PDR does nothave reliable HBsAg prevalence data among healthy adults, andmothers of childbearing age are considered the major source ofhepatitis B infection for children; and 3) our pilot survey revealed
that between 20 and 25 mother and child pairs can be practicallysampled from each village.

Calculation of sample size
The equation used to calculate the required sample size is asfollows [15,16]:
n~Z2 |p(1{p)DEFF |2 ðd 2 |RRÞwhere n = sample size
Z = significance level for 95% confidencep = expected prevalence
DEFF = design effectd = precision
RR = response rate
The sample size (n) of 961 was calculated on the basis of an
expected HBsAg seroprevalence (p) of 5%, a 5% level ofsignificance (Z), precision (d) of 62.0%, design effect (DEFF) of
2.0, two strata, and response rate (RR) of 95%. For fieldpracticability, we requested 24 survey teams to sample 21 childand mother pairs from each cluster, with the aim of gathering
1,008 pairs in total.

Survey design and sampling
The survey applied a stratified three-stage random cluster
sampling design, a type of probability sampling recommended by
the WHO [15,17]. The survey was carried out by 24 survey teams(two members per team). Team members were recruited from thesame districts that were under investigation to implement thesurvey more smoothly. The survey teams consisted of epidemiology, surveillance, or laboratory staff. The survey teams weresupervised by 11 national personnel (six from the National
Immunization Program and five from the National Center for
Laboratory and Epidemiology, Ministry of Health) as well as 13
provincial officers.
For stratified multistage cluster sampling, immunization coverage by district and population data were obtained from the
National Immunization Program, the Ministry of Health, and theDepartment of Statistics, Lao PDR. For post-survey weightadjustment, the survey teams obtained the latest population datafrom village leaders or health volunteers.
All 143 districts in Lao PDR were stratified into two strata, one
having high (more than 76%) and the other having low (76% orless) immunization coverage for the third diphtheria, pertussis,
tetanus, and hepatitis B (DPT-HepB)vaccines as reported in 2010.
For the first stage, we selected 12 districts from each stratum using
probability proportionate to size (PPS) sampling based on the
population census of 2005. For the second stage, we selected twovillages from each selected district by PPS sampling, and 48

Methods
Ethical considerations
The survey protocol was reviewed and approved by the EthicalCommittee of the Ministry of Health, Lao PDR, and theinstitutional review board of the National Center for Global
Health and Medicine, Japan (NCGM-G-001130-00). Access toselected households was granted by the Ministry of Health, andthe provincial and district government authorities.
After obtaining approval to conduct the survey from local
authorities, surveyors explained the purpose of the survey to village
leaders, selected participants, and their caregivers, assured themthat all information would be strictly confidential and that nonames would be gathered, and that there would be no benefit or
penalties for agreeing or refusing to participate. Written informed
consent was obtained from each mother on behalf of her child foreach pair. Written informed consent was obtained from legal
representatives (next of kin, caregivers, or guardians) when

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NJ, USA) and glass capillary tube, and the blood was applied onto
the sample pad of the rapid test kit. After applying the chasebuffer, surveyors assessed the results after at least 15 minutes, but
no longer than 24 hours. When no control bar appeared after 15
minutes, the test results were considered invalid, and the test was
repeated. Blood spots were collected onto filter paper for further
testing. A 2-day training session was organized for surveyors andsupervisors on the use of the rapid test and the completion of thequestionnaire. To ensure the safety of the blood collection
procedure, surveyors always used a new pair of latex gloves.
Surveyors were instructed to place all capillary tubes and lancets
into safety boxes immediately after use.

villages were randomly sampled in total. In the instances in which
the selected village lacked a sufficient number of children or thesurvey team could not approach the selected village due to safety
or security reasons, the nearest village on the way back to the
district center was selected. For each selected village, surveyors
obtained a list of households, including age and sex, primarily
from the poverty reduction program data with the assistance of thevillage leader, women’s union, and/or healthcare volunteer. Fromthese lists, 21 mothers aged 15 to 45 years old with children aged 5
to 9 years were randomly selected using a paper-based lottery
system. When a mother had multiple children aged 5 to 9 years
old, the youngest child was chosen for the survey. Special attention
was paid to ensure that the child’s biological mother was surveyed,
as adoption is common in rural Lao PDR.
The survey was carried out from January 25th to February 4th,
2012. Each survey team successfully approached their assigned
villages, with the exception of one village, which could not be
visited because of road difficulties. An alternative village waschosen according to the predetermined selection criteria. In total,
1,008 children and 1,008 mothers were sampled. The overall
response rate for HBsAg was 100%; however, 43 pairs were
excluded from the analysis due to age ineligibility. That is, one
child was over 9 years of age and 33 were less than 5 years of age.
Furthermore, three mothers were over 45 years of age and six
were less than 15 years of age. This happened as 43 mothers
confused calendar age with traditional age. In rural areas,
newborns start at one year old and a year is added to their age
for each passing of a Lunar New Year. The surveyors asked
participants for their age in years and their date of birth, andchecked that they matched. A total of 965 pairs were included foranalysis.

Data entry and statistical analysis
All of the completed questionnaires were brought to acentralized location and the data were entered into a Microsoft
Excel 2007 spreadsheet. Data were double-entered and crosschecked. Logistic regression tests and odds ratios were used to
examine the relationship between the independent variables and
HBsAg results. Multivariate logistic regression was used toinvestigate the independent association of different household
and individual characteristics with the odds of being HBsAg
positive. All estimates and standard errors were calculated bytaking the multistage clustered sampling design and the weight ofeach sample into account to give representative, unbiased results.
A p value ,0.05 was considered statistically significant.
In our regression analyses, we adjusted for potential confounders by using the following variables: third DPT-HepB immunization coverage at the location of current residence, mother’s age,
ethnic group, mother’s education level, family head’s occupation,and mother’s HBsAg status. For multivariate logistic regression
analyses, multicollinearity was tested by calculating the varianceinflation factors for each independent variable, and a value ofmore than 10 was considered as having multicollinearity.
All statistical analyses were carried out using STATA version 12(Stata Corp., College Station, TX). Means and proportions were
calculated using STATA’s ‘svy’ function, with each sample
weighted according to estimated population size.

Questionnaires
A brief face-to-face questionnaire was administered to thesampled mother. The questionnaire consisted of 25 questions infour domains of inquiry: sociodemographic background of thefamily (i.e., ethnicity, family head’s occupation, and mother’s
education level), family history of liver diseases, including mother,demographic characteristics of the child (i.e., age, sex, and place ofbirth), and immunization records. Additionally, questions wereasked regarding exposure to potential risk factors for acquiring
hepatitis B infection (e.g., history of blood transfusion, surgicaloperation, and sharing of toothbrush). The questionnaire wasdeveloped in English, translated into Lao, back-translated into
English, and then compared and revised by bilingual staff
members. A small pilot test was conducted prior to the datacollection.

Results
Socioeconomic backgrounds
The baseline characteristics of the 965 mothers and theirchildren are summarized in Table 1. The mean age of the mothers
was 29.1 years (95% CI: 26.2–33.1), and the mean age of thechildren was 5.8 years (95% CI: 5.4–6.3). Of the sampled children,
474 (49.4%) were male and 486 (50.6%) were female (five were
unknown).

Testing for HBsAg

HBsAg prevalence among the general population

We used a simple and rapid test (Alere Determine HBsAg test
card; Alere Medical Co. Ltd., Chiba, Japan) rather than the
traditional ELISA test, as it was better suited to use in the field[14]. The sensitivity and specificity of the test were reported ashigh in two Asian countries [18,19]. In Vietnam, the Determine
HBsAg test validity was measured based on comparison with
HBsAg EIA. Results were 100% in both sensitivity and specificity
in 328 samples [18]. In China, the Determine HBsAg performance was evaluated in comparison with HBsAg EIA for 671
samples. The sensitivity was reported to be 98.9% and specificity
100% [19]. The Determine HBsAg examination kit is one of themost reliable point-of-care HBsAg tests, and is recommended by
the WHO [15]. HBsAg testing was performed according to the
manufacturer’s instructions. Blood was collected from a finger
prick using a safety lancet (BD Safety Lancet, Becton Dickinson,
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Of the 965 pairs included in the study, 17 children and 27
mothers were positive for HBsAg. Six child and mother pairs were
HBsAg positive. The estimated prevalence was 1.7% for children(95% CI: 0.8%–2.6%) and 2.9% for mothers (95% CI: 1.7%–
4.2%) after taking the sampling design and weight of each sample
into account. HBsAg prevalence did not change significantly
between DPT-HepB3 high and low coverage districts in bothchildren and mothers (Table 2).

Potential risk factors
To determine whether background characteristics affect HBsAg
status, we conducted multivariate logistic regression analysis inchildren and their mothers. In children, the mother’s HBsAg status
was positively associated with hepatitis B infection (Table 3),
3

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Table 1. HBsAg prevalence among children (5 to 9 years old) and mothers (15 to 45 years old) in Lao PDR by selected backgroundcharacteristics.

Mothers’ age(n = 965)

Ethnicity (n = 963)

1

Transportation (n = 939)

2Time (n = 901)

3

Education (n = 962)

4

Occupation (n = 963)n%Children’s
HBsAg (+)%

Mothers’
HBsAg (+)

%

15–19

4

0.41

0

0.00

20–24

85

8.80

1

1.18

0.00–3.52

0

0.00

3

25–29

294

30.47

7

2.38

3.53

0.00–7.53

0.63–4.13

8

2.72

30–34

275

28.50

6

0.85–4.59

2.18

0.44–3.92

9

3.27

35–39

176

18.24

1.16–5.39

3

1.70

0.00–3.64

3

1.70

40–45

131

0.00–3.64

13.58

0

0.00

4

3.05

Low land Lao

0.07–6.04

651

67.60

9

1.38

0.48–2.28

19

2.92

1.62–4.22

Mid land Lao

248

25.75

6

2.42

0.49–4.34

5

2.02

0.25–3.78

High land Lao

64

6.65

2

3.13

0.00–7.51

3

4.69

0.00–10.01

on foot

298

31.74

1

0.34

0.00–1.00

6

2.01

0.41–3.62

bicycle

14

1.49

0

0.00

0

0.00

motor bike

364

38.76

7

1.92

0.51–3.34

10

2.75

1.06–4.43

car

183

19.49

5

2.73

0.35–5.12

6

3.28

0.67–5.88

hand tractor

66

7.03

3

4.55

0.00–9.71

4

6.06

0.15–11.97

other

14

1.49

0

0.00

0

0.00

95% CI

95% CI, 5 minutes

31

3.44

0

0.00

1

3.23

0.00–9.81

5 to 15 minutes

274

30.41

3

1.09

0.15–2.33

6

2.19

0.45–3.93

15 to 30 minutes

231

25.64

5

2.16

0.27–4.06

11

4.76

2.00–7.53

30 to 60 minutes

209

23.20

5

2.39

0.30–4.48

4

1.91

0.04–3.79. 60 minutes

156

17.31

3

1.56

0.00–4.68

42.56

0.06–5.07

did not finish primaryschool

307

31.91

7

2.28

0.60–3.96

12

3.91

1.73–6.09

primary school

374

38.88

5

1.34

0.17–2.51

10

2.67

1.03–4.32

junior high

185

19.23

3

1.62

0.00–3.46

2

1.08

0.00–2.59

high school

73

7.59

0

0.00

1

1.37

0.00–4.10

college/univ

20

2.08

1

5.00

0.00–15.47

2

10.00

0.00–24.41

other or unknown

3

0.31

1

33.33

0.00–100.00

0

0.00

0.88–2.93

19

2.78

0

0.00

farmer

683

70.92

13

1.90

fisherman

5

0.52

0

0.00

laborer

92

9.55

1

1.09

0.00–3.25

55.43

0.71–10.16

public officer

88

9.14

1

1.14

0.00–3.40

36.25

1.70–10.80

factory employee

8

0.83

0

0.00

0

0.00

general employee

16

1.66

1

6.25

0.00–19.57

0

0.00

merchant

63

6.54

1

1.59

0.00–4.76

00.00

others

8

0.83

0

0.00

0

0.00

Mother’s surgery(n = 962)

yes

95

9.88

2

2.11

0.00–5.05

3

3.16

0.00–6.74

no

867

90.12

15

1.73

0.86–2.60

24

2.77

1.67–3.86

Child’s sex (n = 960)

male

474

49.38

9

1.89

0.67–3.13

female

486

50.63

7

1.44

0.38–2.50

Place of delivery(n = 961)

province hospital

207

21.54

4

1.93

0.04–3.82

6

2.90

0.59–5.20

district hospital

105

10.93

2

1.90

0.00–4.56

5

4.76

0.62–8.90

health center

10

1.04

0

0.00

0

0.00

private clinic

11

1.14

0

0.00

1

9.09

0.00–29.35

at home

569

59.21

8

1.41

0.44–2.38

14

2.46

1.18–3.74

in the forest

56

5.83

3

5.36

0.00–11.44

1

1.79

0.00–5.36

other health facility

3

0.32

0

0.00

0

0.00

yes

22

2.29

0

0.00

Child’s surgery (n = 960)

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440 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

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Table 1. Cont.

no

n

%

Children’s
HBsAg (+)%

95% CI

938

97.71

16

1.71

0.88–2.54

Mothers’
HBsAg (+)%

95% CI

1
Transportation to the nearest health facility, 2 Time to the nearest health facility, 3 Mothers’ completed education, 4 Family head’s occupation.
doi:10.1371/journal.pone.0088829.t001

whereas the other potential risk factors were not associatedaccording to the adjusted odds ratio. We did not obtain
information regarding the type of delivery, and we did not findsignificant differences in HBsAg prevalence associated withdelivery settings. No independent factor was positively associatedwith HBsAg positivity in mothers, according to the adjusted odds
ratio (Table 4).

the study design is a cross sectional survey, it is difficult to explain
the reasons for the unexpectedly low prevalence. There are several
potential explanations for this observation. The survey methodology used was very different from that used for blood donors,
patients, and migrant workers. We used probability sampling andthus the results are representative of the whole population,
whereas studies of blood donors, hospitalized patients, andmigrant workers used non-probability sampling and therefore
the results are restricted to these populations. The primaryobjective of our survey was to estimate HBsAg prevalence among
the general population, so probability sampling was the mostappropriate choice. Demographic conditions among the sampled
population are determined by survey methodology, and therefore
the results showed discrepancy. The WHO strongly recommends
probability sampling for hepatitis B prevalence survey [7,15,17].
Although Lao PDR has the lowest population density of the
Indochina peninsula countries [25], the precise effects on hepatitis
B prevalence of the reduced frequency of human to humancontact due to the country’s relatively low population density andless developed infrastructure remain unclear.
The number of HBsAg positives varied from 0 to 4 per cluster.
Since the sampling design of the survey aimed to estimate theprevalence in the whole country, it is difficult to determine
whether these differences reflect the local endemic status.

Immunization status
Written immunization records were available for 213 out of 965
children (22.1%). One hundred ninety eight children were
vaccinated with three doses of hepatitis B vaccine, and 34 children
were immunized on the day of birth or the following day. Five outof 213 children with immunization records were HBsAg positive(2.35%; 95% CI: 0.30–4.40%), while 12 of 752 without
immunization records were HBsAg positive (1.60%; 95% CI:
0.70–2.49%). The differences between the two groups were notsignificant (p = 0.46).

Discussion
HBsAg prevalence among the general population
The estimated HBsAg prevalence in the general population wasmuch lower in both children and adults than that of previous
reports from neighboring countries and Lao PDR. For example,
HBsAg prevalence in adults in Cambodia, Thailand, and Vietnam
was reported to be 7.7% (95% CI: 6.2%–9.3%) [12], 6 to 10%[15,20], and 18.8% (95% CI: 15.7%–21.9%) [13], respectively.
Data on HBsAg prevalence amongst children was relatively scarce,and reported to be 3.5% (95% CI: 2.4%–4.8%) in Cambodia [21],and 18.4% (95% CI: 13.4%–23.4%) in Vietnam [13]. In Lao
PDR, studies in blood donors, hospitalized patients, and Lao
migrant workers tested in Thailand showed HBsAg prevalence of
8.73% (95% CI: 8.69%–8.77%) [22], 17.99% (95% CI: 17.81%–
18.17%) [23], and 6.86% (95% CI: 6.80%–6.92%) [24] basedon the given numerators and denominators in the articles,
respectively.
Since the study objective was to estimate the nationwide HBsAg
prevalence among the general population of Lao PDR, and thus

Potential risk factors
Our survey revealed that no potential risk factors weresignificantly associated with the children’s infection status, withthe exception of the mothers’ hepatitis B infection status. HBsAg
prevalence surveys in other countries revealed that history ofsurgery [26,27], level of education [26], and ethnicity [28] wereindependently associated with hepatitis B infection. The reason
why we could not find any potential risk factors positively
associated with hepatitis B infection among children is not clear.
However, it should be noted that the primary objective of thepresent study was to assess HBsAg prevalence, and not its risk
factors. Additionally, some reports found that HIV positive
individuals are positively associated with hepatitis B virus infection

Table 2. HBsAg prevalence among children (5 to 9 years old) and mothers (15 to 45 years old).

Children’s
HBsAg (+)%

95% CI

Standard
error

DesigneffectMothers’
HBsAg (+)%

95% CI

Standard
error

DesigneffectHigh coverage
districts(n = 486)6

1.14

0.23–2.04

0.44

0.82

18

3.79

1.79–5.79

0.97

1.24

Low coverage
districts(n = 479)

11

2.39

0.75–4.03

0.79

1.27

9

1.88

0.49–3.37

0.69

1.22

Total (n = 965)

17

1.72

0.81–2.63

0.44

1.10

27

2.93

1.65–4.20

0.61

1.28

doi:10.1371/journal.pone.0088829.t002

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Table 3. Unadjusted and adjusted odds ratio for being HBsAg positive among children from five to nine years old in Lao PDR by
selected background characteristics.

Unadjusted
odds ratio
DPT3 coverage

high

95% CIp

Adjustedodds ratio

95% CIp

0.73–6.21

0.16

3.47

0.77–15.64

0.10

0.28–1.78

0.44

0.87

0.31–2.47

0.79

0.67–5.40

0.22

1.41

0.26–7.72

0.68

0.67–3.36

0.30

1.03

0.27–3.89

0.96

0.37–3.64

0.80

0.60

0.18–1.96

0.38

0.21–2.62

0.63

0.65

0.21–2.08

0.46

0.39–2.49

0.97

0.79

0.28–2.21

0.64

9.45–61.07

0.00

28.13

10.21–77.53

0.00

1(reference)

low

2.13

Mothers’ age

15 to 291(reference)

30 to 45

0.70

Ethnicity

Low land Lao1(reference)others1.90

Educationnone

1(reference)

finished primary school or upper

1.50

Occupation

white collar1(reference)blue collar

1.15

Sex

male

1(reference)

female0.75

Birth place

health facility1(reference)

non-health facility

0.98

Mothers’ HBsAg

negative1(reference)

positive24.02

doi:10.1371/journal.pone.0088829.t003[29,30]; however, we did not investigate HIV due to limited
budget.

PDR achieved the target through the immunization program
alone because the country has the lowest immunization coverageof all countries in the region [7,9]. Considering the relatively lower
HBsAg seroprevalence among the mothers compared to thosereported in previous studies, it is likely that Lao PDR had a lower
prevalence even before the introduction of the hepatitis B
immunization program. Therefore, the final target of reducing
HBsAg prevalence to less than 1% in children aged at least 5 years
could be difficult to achieve if the country simply continues its
current immunization policy.
A nationwide prevalence survey targeting the general population is ideally conducted before implementing the immunization

WHO’s regional target
The interim target of the WHO is to reduce HBsAg prevalence
to less than 2% in children aged at least 5 years old by 2012 [7,31].
The point prevalence is used for monitoring the control ofhepatitis B. The Regional Office for the Western pacificrecommended that the country conduct a national HBsAg
prevalence survey to verify whether the country has reached theregional prevalence target [9]. Following these criteria, Lao PDR
had already achieved its goal. However, it is unlikely that Lao

Table 4. Unadjusted and adjusted odds ratio for being HBsAg positive among mothers from 15 to 45 years old in Lao PDR by
selected background characteristics.

Unadjusted
odds ratio
DPT3 coverage

high

95% CIp

Adjustedodds ratio

95% CIp

0.20–1.28

0.14

0.47

0.19–1.16

0.10

0.43–2.51

0.94

0.94

0.39–2.25

0.88

0.30–2.17

0.65

0.68

0.25–1.85

0.44

0.70–4.01

0.23

2.04

0.89–4.68

0.09

0.53–5.55

0.35

1.93

0.68–5.50

0.21

0.39–4.25

0.67

1.30

0.35–4.78

0.68

1(reference)

low

0.50

Mothers’ age

15 to 291(reference)

30 to 45

1.03

Ethnicity

Low land Lao1(reference)others0.80

Educationnone

1(reference)

finished primary school or upper

1.68

Occupation

white collar1(reference)blue collar

1.71

History of surgery

no1(reference)

yes

1.28

doi:10.1371/journal.pone.0088829.t004

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642 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

February 2014 | Volume 9 | Issue 2 | e88829

Annex 6: Published article

Hepatitis B Prevalence in Child and Mother Pairs

females was 6.2% [22]. When considering the disease burden ofhepatitis B virus infections, it is better to include both sexes [26].
To the best of our knowledge, this is the first nationwide,
population-based serological survey on chronic hepatitis B virus
infections both before and after implementation of hepatitis B
immunization in Southeast Asia, where disease burden is high. As
such, our results provide valuable information on a hepatitis B
immunization program and a useful baseline against which tocompare future assessments in this region.
National immunization policy should be based on the disease
epidemiology [3]. However, in Southeast Asia, understanding of
the epidemiology of hepatitis B remains unsatisfactory. Even whena country implements a hepatitis B immunization program forchildren and the prevalence of disease reaches the target (i.e., lessthan 2% among children aged 5 years or older), we cannot
conclude that the immunization program alone contributed toreduced disease prevalence without comparing it to the diseaseprevalence in the pre-vaccine generation, i.e., adults. Nationwide
surveys assessing disease prevalence in the generations before andafter the implementation of a vaccination program will provide
valuable information for understanding hepatitis B epidemiology.
Therefore, we recommend surveying hepatitis B seroprevalence inboth generations.

strategy to evaluate hepatitis B epidemiology. However, we wereable to understand the epidemiology to some degree, even after
implementation of immunization policy, because adults usually
represent the pre-vaccination era [15,17].

Strengths of the study
The present study is the first nationwide survey on theprevalence of hepatitis B in the general population both before
and after the implementation of a hepatitis B immunization policyin Lao PDR and other Southeast Asian countries. We applied
multistage stratified cluster sampling to better represent thegeneral population. The design effect of prevalence was calculated
between 0.8 and 1.3, which was acceptable as we set it around 2.0
before the survey.
The background characteristics of our sampled population weresimilar to those of another nationwide population-based study, theLao PDR Reproductive Health Survey (LRHS) [32] conducted in
2005. For example, the locations of current residence (north,central, and south) were 33.3%, 41.7%, and 25.0% in our survey,
and 38.6%, 38.9%, and 22.5% in the LRHS. The levels of
mothers’ completed education (none, primary school, secondary
school or more) were 31.9%, 38.9%, and 29.2% in our survey, and28.8%, 43.7%, and 27.5% in the LRHS. The LRHS applied themultistage stratified cluster sampling method and surveyed morethan 13,000 women all over the country. A direct comparison of
the populations sampled by the two different surveys is difficult toperform as the primary objectives were different. Despite this, oursampled population is considered to likely represent the general
population in Lao PDR.

Conclusions
We determined the nationwide HBsAg prevalence amongchildren (1.7%; 95% CI: 0.8%–2.6%) and their mothers (2.9%;
95% CI: 1.6%–4.2%) in Lao PDR. This is the first report toestimate the nationwide prevalence of chronic hepatitis B in preand post-hepatitis B immunization generations in Southeast Asia,
where hepatitis B infections are a substantial burden. The
estimated prevalence was below that of previous studies, suggestingthat our understanding of this disease’s epidemiology is lacking
and warrants further investigation. We recommend that theprevalence among the pre- and post-vaccine eras should be
investigated when conducting hepatitis B seroprevalence surveys.

Limitations of the study
There are several limitations in our study that should be
addressed. First, the population data is based on the census
conducted in 2005. After 2005, the population distribution may
have changed and some of the villages could have merged, thereby
creating bias in the findings. Fortunately, we did not survey any
villages that disappeared or merged.
Second, floating or marginal populations are likely to be missedfrom the residential lists, and these populations could be a sourceof HIV and hepatitis B virus infections [33]. In futureseroprevalence surveys, these subpopulations should be accounted
for by using specific approaches, such as oversampling.
Third, population immunity levels were difficult to measure or
estimate. The possession of immunization certificates was low,
because many participants had already finished their scheduled
vaccinations before 12 months of age, and relevant documents
were lost. In the present study, we did not have enough data fromhealth centers due to time and budget limitations. Since we did not
examine immunization markers, such as HBsAb, herd immunity
levels are unknown.
Lastly, adult men were not included in the survey. Serologicalstudies in the past indicated that men have higher HBsAg rates
than women [8,21,28]. In Lao PDR, male blood donors presented
with 9.7% HBsAg positive prevalence, while the prevalence inAcknowledgments
We would like to express our sincere thanks to the sampled children,
mothers, and caregivers for their voluntary participation in the survey. We
are grateful to all of the surveyors and supervisors from the National
Immunization Program, National Center for Laboratory and Epidemiology, Ministry of Health, and staff from the provincial and district
Departments of Health. We would also like to thank Dr. H. Murakami foradvising on the survey methodology, and Drs. S. Noda, Y. Sugiura, H.
Okabayashi, A. Iwamoto, and M. Anami for their critical comments
regarding the field survey, and Dr. Y. Horikoshi for geographical analysis.

Author Contributions
Conceived and designed the experiments: AX MH KI TW MS. Performed
the experiments: KK TK PV CP KP DP BS VSO TS. Analyzed the data:
KK TK MH. Contributed reagents/materials/analysis tools: KI TW MS.
Wrote the paper: AX PV MH. Revised the manuscript: KK TK PV CP
KP DP BS VSO KI TW MS. Arranged laboratory for diagnosis: PV KI
TW MS.

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Hepatitis B Prevalence in Child and Mother Pairs

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44 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

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Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 45

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48 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR®÷¡ºñ¡¦º−-ª¸
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DPT-HepB 3

Diphtheria, pertussis, tetanus, hepatitis B vaccine the third dose

EPI

Expanded Programme on Immunization

HB

Hepatitis B

HBsAg Hepatitis B surface antigen
JICA

Japan International Cooperation Agency

MoH

Ministry of Health, Lao PDR

NCGM National Center for Global Health and Medicine
NCLE

National Center for Laboratory and Epidemiology, MoH

NIPNational immunization Program, Maternal and Child Health, MoH

PPS

Probability proportionate to size

SBA

Skilled birth attendance

VPD

Vaccine preventable diseases

WHO

World Health Organization

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 49

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95% C.I.
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1.7%

0.8-2.6%

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(n=965)ª¾ª½ì¾¤.

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2.4%

0.8-4.0

1.1%

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1.9

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8.8

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1.2

0.0-3.53

3.5

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294

30.5

7

2.4

0.6-4.18

2.7

0.9-4.6

30-34

275

28.5

6

2.2

0.4-3.99

3.3

1.2-5.4

35-39

176

18.2

3

1.7

0.0-3.63

1.7

0.0-3.6

40-45

131

13.6

0

0.0

4

3.1

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651

67.6

9

1.4

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19

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248

25.8

6

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5

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298

31.7

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183

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66

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15-30 −¾êó

231

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11

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209

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156

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185

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3

1.6

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73

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20

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62 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

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1. ¡¾−¥ñ©-ª˜¤-¯½ªò®ñ©-¡¾−-£í−£¸É¾¡¾−-£í−£¸É¾-§º¡-¹¾-ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò© -®ó Ã−-£˜¤-−šÄ©É-»ñ®°ö−¦¿-Àìñ©-ìö¤-Ä©É-Á´È−-À−ˆº¤-´¾¥¾¡-À¹©°ö−-ªÈ¾¤Å-©„¤-ì÷È´-−š: 1) ¡½§¸¤-¦¾ê¾ì½−½-¦÷¡ -Á¹È¤ ¦¯¯ì¾¸ -Ä©É-´ó-£¸¾´-´÷È¤-Ï˜−-µÈ¾¤-¨…¤-ê†-¥½©¿-À−ó−-¡¾−¦¿-Í¸©.
2) ¡¾−-¦ˆ¦¾− Áì½ ¡¾−-¯½¦¾−-¤¾−-Á´È−Ä
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3) º¿−¾©-¡¾−-¯ö¡£º¤-êÉº¤-«…− Áì½ º¾¦¾-¦½Ïñ¡-¦¾ê¾ì½−½-¦÷¡-Á´È−-´ó-¦È¸−-»È¸´-−¿-¡ñ−-À¯ñ−-µÈ¾¤-©ó.
4)

êó-´¤¾−¡¾−£í−£¸É¾-Á´È−Ä
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2. ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò©-®ó-Ã−-À©ñ¡−Éº¨ -Áì½ -Á´È¨ò¤Ä- ¸-¥½-Àìó-−²ñ−ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò©-®ó-Ã−¯½§¾¡º−-ê‰¸Ä- ¯-¢º¤-¦¯¯ì¾¸ -Á´È−-ªÔ-Í¾¨¡¸È¾¡¾−-£¾©-£½-À−Ä¸ÉÂ©¨ªÔ-êñ¤-¢º¤-À©ñ¡

Áì½°øÉ-Ã¹¨ú,À§…¤ªÔ-¡¸È¾ºñ©ª¾-¡¾−-ªò©-À§œºê†Ä- ©É-«õ¡-ì¾¨-¤¾−-¢º¤-®ñ−©¾¯½-Àê©-À²ˆº−®É¾−-¢º¤--ì¾¸ [7, 8, 9]. ªö¸µÈ¾¤-À§„−: ºñ©ª¾-¡¾−-ªò©-À§œººñ¡À¦®-ªñ®-§½−ò©-®óÃ−-°øÉ-Ã¹¨ÈµøÈ-¯½-Àê©-¡¿¯ø-À¥¨, Ä- ê Áì½¸¼©−¾´-Á´È− 7.7% (95% CI: 6.2% -9.3%) [10], 8.9% [11], -Áì½ 18.8% (95% CI: 15.7 % -21.9%) [12]ª¾´-ì¿©ñ®. ¢Ó-´ø−-¢º¤ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò©-®-Ãó −-À©ñ¡−Éº¨−š-Á´È−-¢Éº−-¢É¾¤-¹¾-¨¾¡ -À§…¤´ó£È¾-¯½´¾−
3.5% (95% CI: 2.4% -4.8%) µøÈ¡¿-¯ø-À¥¨ [13], -Áì½ 18.4% (95% CI: 13.4% -23.4%) µøÈ-¸¼©−¾´ [12]. ´ó£¿-º½êò®¾¨-ê†-´ó-¦ñ¡¡½-¨½-²¾®-Í¾¨-µÈ¾¤-ªÒ-°ö−-Ä©É-»ñ®-−š-À§„−:1) £¸¾´-Î¾-ÁÎÉ−-¢º¤-¯½§¾¡º−-¢º¤ ¦¯¯ì¾¸ -Á´È−-ªÔ-¡¸È¾-®ñ−©¾-¯½-Àê©-ºÉº´-¢É¾¤-À»ñ©-Ã¹É¡¾−-ªò©-ªÒ-²ö¸²ñ−¡ñ®-®ñ−©¾-¯½-Àê©-ºÉº´-¢û¾¤−˜−-®Ò-¦½ÏÔ¦½-ÀÏó [14]. −º¡¥¾¡-−˜−-ÁìÉ¸, «½Îö−-¹ö−ê¾¤, ê¾¤-ìö©-Ä³, ¡¾−®ò−, -Áì½
²œ−«¾−Â£¤-ìÈ¾¤-Á´È−´ó-¡¾−-²ñ©ê½−¾-ÎÉº¨-Ã− ¦¯¯ ì¾¸, ©„¤-−˜−¥‡¤-À»ñ©-Ã¹É-´Âó- º¡¾©-ÎÉº¨-Ã−¡¾−Á°È-¡½¥¾¨-¢º¤À§œº-¥÷ì½-Âì¡. ºó¡-©É¾−-Î‡¤, £¸¾´-Áª¡-ªÈ¾¤-ê¾¤-©É¾−-¸ñ©ê½−½ê¿- Áì½¡¾−-¯½²ô©º¾©-À»ñ©-Ã¹Éºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡À¦®-ªñ®-§½−ò©-®ó-ªÔÃ− ¦¯¯ ì¾¸.
2) ¦È¸−-Ã¹¨ÈÁìÉ¸°ö−-Ä©É-»ñ®¢º¤-¡¾−-¦¿-Í¸©-Ã−-£˜¤ê†-°È¾−-´¾-Á´È−-®Ò-Ä©É-¢½Î¾©-ªö¸µÈ¾¤-²¼¤²ð-ê†-¥½-À¯ñ−-ªö¸-Áê−-Ã¹ÉÁ¡È-¯½§¾¡º−êñ¤-Ïö©Ã−ê‰¸-¯½-Àê©Ä©É. ªö¸µÈ¾¤-À§„−: ¡¾−-¦ô¡¦¾-Î‡¤-Ã−-£ö−-®ðìò¥¾¡-Àìõº©-Ã− ¦¯¯ì¾¸ ¦½-Á©¤-Ã¹ÉÀ¹ñ−ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò©-®ó Á´È−Ã−ì½¹¸È¾¤ 7.2% ¹¾ 9.7% -Ã−¡÷È´-º¾¨÷-ê†-Áª¡-ªÈ¾¤-¡ñ− [15].
ºó¡-¡¾−-¦ô¡¦¾-Î‡¤-Ã−-£ö−-À¥ñ®-−º−Â»¤Ïð-Ä©É-À¯ó©-À°ó¨-Ã¹É-À¹ñ−-À«ò¤-ºñ©ª¾-§÷¡-§÷´-¢º¤-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò©-®ó- -Ã−°øÉ-Ã¹¨È-µøÈ-−½£º−-−Í¸¤-¸¼¤-¥ñ−Á´È− 18.0% [16]. Ã−¢½−½-ê†-¡¾−-¦ô¡¦¾-ÀÍ‰¾-−š-´ó-ºñ©ª¾-§÷¡-§÷´-¦ø¤, ¡÷È´-¯½§¾¡º−ªö¸µÈ¾¤-Ã−-¡¾−-¦ô¡¦¾-−š-®Ò-¦¾´¾©-À¯ñ−-ªö¸-Áê−-¢º¤-¯½§¾¡º−-ê‰¸Ä- ¯-Ä©É.
3. ²œ−-ê†-À¯í¾-Ï¾¨-¢º¤-ºö¤¡¾−-º½−¾-Ä´-Âì¡-Ã−-¢ö¤-À¢©-²ø´ò-²¾¡-À¯í¾-Ï¾¨-¢º¤-ºö¤¡¾−-º½−¾-Ä´-Âì¡-Á´È−¡¾−-ÍÐ©°Èº−ºñ©ª¾¡¾−ªò©-À§œººñ¡-À¦®-ªñ®§½−ò©-®ó−Éº¨º¾¨÷-ÍÐ©

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64 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR£õ-£¸−-´ó-¡¾−-¦÷È´-ªö¸µÈ¾¤-¥¾¡-À¢í¾-À¥í¾-Ã¹É-

- Àº¡-¡½¦¾−ºÉ-−ºÉ¾¤-¤ºó-º¤óÀº¡¡½¦¾¡½¦¾−º

1. Kane MA. (1996) Global status of hepatitis B immunization. Lancet 348: 696.
2. Lee WM. (1997) Hepatitis B virus infection. N Engl J Med 337: 1733–1745.
3. World Health Organization (2009) Hepatitis B vaccines. Wkly Epidemiol Rec 84: 405-419.
DOI:
4. Goldstein ST, Zhou F, Hadler SC, Bell BP, Mast EE, et al. (2005) A mathematical model toestimate global hepatitis B disease burden and vaccination impact. Int J Epidemiol 34:
1329–1339.
5. World Health Organization (2005) WPR/RC56.R8. Measles elimination, hepatitis B
control and poliomyelitis eradication. Available:
http://www2.wpro.who.int/rcm/en/archives/rc56/rc_resolutions/wpr_rc56_r08.htm. Accessed
25 May 2013.
6. World Health Organization (2011) Progress towards meeting the 2012 hepatitis B control
milestone: WHO Western Pacific Region, 2011. Wkly Epidemiol Rec 86: 180-188.
7. Rani M, Yang BP, Nesbit R (2009) Hepatitis B control by 2012 in the WHO Western
Pacific Region: rationale and implications. WHO Bull 87: 707-713. DOI:
8. Lueng N (2009) Chronic hepatitis B in Asian women of childbearing age. Hepatol Int 3:
S24-S31.
9. Clements CJ, Baoping Y, Crouch A, Hipgrave D, Mansoor O, et al. (2006) Progress in thecontrol of hepatitis B infection in the Western pacific Region. Vaccine 24: 1975-82.
10. Ol HS, Bjoerkvoll B, Sothy S, Heng YV, Hoel H, et al. (2009) Prevalence of hepatitis B
and hepatitis C virus infections in potential blood donors in rural Cambodia. Southeast
Asian J Trop Med Public Health 40: 963-971.
11. Duong TH, Nguyen PH, Henley K, Peters M (2009) Risk factors for hepatitis B infection
in rural Vietnam. Asian Pacific J Cancer Prev 10: 97-102.

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 65

12. Hipgrave DB, Van NT, Huong VM, Long HT, Dat DT, et al (2003) Hepatitis B infection inrural Vietnam and the implications for a national program of infant immunization. Am J
Trop Med Hyg 69: 288-294.
13. Soeung SC, Rani M, Huong V, Sarath S, Kimly C, Kohei T, et al (2009) Results fromnationwide hepatitis B serosurvey in Cambodia using simple and rapid laboratory test:
implications for national immunization program. Am J Trop Med Hyg 81: 252-257.
14. Population density per square km, World Bank, 2012
http://data.worldbank.org/indicator/EN.POP.DNST
Accessed 1 June 2013.
15. Jutavijittum P, Yousukh A, Samountry B, Samountry K, Ounavong A, et al. (2007)
Seroprevalence of hepatitis B and C virus infections among Lao blood donors. Southeast
Asian J Trop Med Public Health 38: 674-679.
16. Syhavong B, Rasachack B, Smythe L, Rolain JM, Roque-Afonso AM, et al. (2010) The
infective causes of hepatitis and jaundice amongst hospitalised patients in Vientiane, Laos.
Trans R Soc Trop Med Hyg 104: 475-483.

66 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR

²¾¡-²½-Î¸¡²¾¡-²½-Î¸¡²¾¡-²½-Î¸¡

1. À´²¾¡-²½-Î¸¡

2. Á®

²¾¡-²½-Î¸¡

3. Ã®

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4. ª¾²¾¡-²½-Î¸¡

5. ì¾²¾¡-²½-Î¸¡

1. À´õº¤ -Áì½ ®É¾− -ê†-«õ¡-£ñ©-Àìõº¡-À¢í¾-Ã−-¡¾−-¦¿-Í¸©

²¾¡-²½-Î¸¡

2. Á®®-¦º®-«¾´²¾¡-²½-Î¸¡

3. Ã®¨ò−-¨º´²¾¡-²½-Î¸¡

4. ª¾ª½ì¾¤Ã−-¡¾−-±ô¡-ºö®»ö´²¾¡-²½-Î¸¡

5. ì¾¨-§ˆ-°øÉ-À¢í¾-»È¸´-¡¾−-±ô¡-ºö®»ö´£½−½-êó-´¤¾−£í−£¸É¾-¥¾¡ ¦ø−-¡¾−-Á²© -Áì½ ¦÷¢½²¾®-Âì¡-Á¹È¤-§¾©-¨†¯÷È−Masahiko Hachiya (Masa),(Masa) PhD, MD, MPH, is interested in infectious disease surveillance andresponses, especially EPI target diseases. He is a pediatric gastroenterologist and epidemiologist. He
has working experiences for EPI in Bhutan, Mongolia and P.R. China. Masa visited Lao PDR several
times, and worked for the survey planning, implementation, and feedback to MoH. He also worked forpoliomyelitis eradication effort in Pakistan. E-mail to: m-hachiya (at) it.ncgm.go.jp
Kenichi Komada (Ken),(Ken) MD, MPH, is interested in infectious disease epidemiology, especially forperinatal infection such as hepatitis B, HIV, and syphilis. He is a general surgeon and a specialist for
emergency medicine. He worked for safety blood in Myanmar, and ART services and PMTCT in
Zambia. For the phase I and II surveys, Ken was in charge of statistical analysis as well as sampling
methods. At the time of this publication, he stays in Lusaka, Zambia as JICA expert on ART.
Tomomi Kitamura (Tommy),(Tommy) MD, MPH, is interested in MCH and nutrition. She is a pediatrician andneonatologist. She worked for pediatric HIV in Nepal, and MCH management in Madagaskar. She
was very well in management of survey implementation. At the time of this publication, she stays in
Honya, Madagascar for her research in MCH.

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Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 75

<ແບບຟອມຕ ົກລ ົງຍິນຍອມສ ໍາລ ັບພໍ່ ແມ>່ພໍ່ ແມທີ່່ ນ ັບຖື,1. ພາກສະເໜີ Introduction້ ະໄດຈ
ການຄນຄບ ັດໂດຍສູນສຸຂະພາບແມ ່ ແລະ ເດັກ, ກະຊວງສາທາລະນະສຸກແຫງ
ົ້ ວ
ັ້ ຈ
ັ້
້ າຄງນີ້ ັດຕງປະຕິ່ ສປປລາວ
, ໂດຍຮວ່ ມມື ແລະ ເປັນເອກກະພາບກ ັບ NCGM (ສູນກາງການແພດ ແລະ ສຸຂະພາບໂລກແຫງ່ ຊາດຍີ່ ປຸນ່ ).
2. ຈຸດປະສ ົງຂອງການຄນຄົ້ ວ້ າ້ ວາ່ ໄວຣ ັດສອພະຍາດອ ັກເສບຕ ັບບີມສີ າເຫດມາຈາກໄວຣ ັດສຊ໌ ະນິດໜຶ່ ງເອີນ໌ ັກເສບຕ ັບຊະນິດບີ. ຖາ້ ຫາກເຮົາໄດ ້້ ໄວຣ ັດສເ໌ ຂົ້າຮາ່ ງກາຍເປັນເວລາດ ົນ ໄວຣ ັດສຈຮ ັບເຊຶອ໌ ະສາມາດກໍ່ ໃຫເ້ ກີດພະຍາດຕັບໄດໃ້ ນພາຍຫຼ ງັ . ມີປະຊາກອນ້ ໄວຣ ັດສຊລາວຫຼາຍຄ ົນທີ່ຖືເຊືອ໌ ະນິດນີ້ (ໃນສ ັດສວ່ ນ 1 ຕໍ່ 5 ຫຼື 6 ຄ ົນ). ການປອ້ ງກ ັນບໍ່ໃຫຮ້ າ່ ງກາຍຂອງທາ່ ນຕິດ້ ມນສິ່້ ເຂົ້າໄປໄວຣ ັດສຊັ ນບ ັນຫາທີ່ຫຍຸງ້ ຍາກໃນການປິ່ ນປົວຜູໃ່ ດຜູໜ໌ ະນິດນີແ່ ງທີ່ ສ ໍາຄ ັນ ເພາະມນເປັ່ ່ ຶງເມື່ ອໄດຮ້ ັບເຊຶອ້ ໄວຣ ັດສຊ້ ມນຄິ້ ມາຈາກແມໃນເວລາໃຫແລວກິ ເຊືອ
້ . ສວ່ ນຫຼ າຍການຕິດເຊືອ໌ ະນິດນີແ່ ດວາ່ ໄດຕ້ ດ່້ ານເກີດລູກ. ທາ່ ນສາມາດຫຼີກລຽ່ ງຈາກພະຍາດນີໄ້ ດ ້ 95% ຖາ້ ຫາກທາ່ ນໄດຮ້ ັບການສ ັກຢາວ ັກແຊງ໋ ໂດຍທັນທີພາຍຫຼ ງັ ທາ່ ນເກີດ.

ກະຊວງສາທາລະນະສຸກແຫງບ ັດໂຄງການສ ັກຢາວ ັກແຊງ໋ ເພື່ ອປອັ້່ ສປປລາວໄດລ້ ເິ ລີ່ ມການຈ ັດຕງປະຕິ້ ງກ ັນການສ່¤ົ້ າກແມຫາລູ້ ໄວຣ ັດສຊກ.
ຜາ່ ນເຊືອ
່໌ ະນິດນີຈ້ ນ້ ໄວຣ ັດສຊ້ າ່ ມີຫຼ າຍສະນນັ້ ກະຊວງສາທາລະນະສຸກໄດຮູ ກຽ່ ວກ ັບແມ ່ ແລະ ລູກທີ່ ໄດຕິ ເຊືອ້ ຽກຮອ້ ງຂໍມ້ ດ໌ ະນິດນີວ່ ັ ກາ່ ວນີເ້ ຂົ້າໃນການປັບປຸງໂຄງການສ ັກຢາປອ້ ໄວຣ ັດສຊປານໃດ ເພື່ ອຈະນ ໍາໃຊຂ
ູ ດງ
ໍ້ ນ
້ ມ
້ ງກ ັນການຕິດເຊືອ໌ ະນິດນີໃ້ ນອະນາຄ ົດ.
3. ການຄ ັດເລືອກຜູຂ
ົ້ ວ
ົ້ ວ
້ າຮ
່ ມໃນການຄນຄ້ າພວກເຮົາÄ- ©É-£ñ©-Àìõº¡-Àºö¾ເດັກນອ
າເຈົ້າ (ອາຍຸ 15 ຫາ 45 ປີ)້ ຍ (ອາຍຸ 5 ຫາ 9 ປີ) ແລະ ແມຂອງເຂົ
່

4. ວິທີການຂອງການຄນຄ
ົ້ ວ
້ າ

້ ມືຂອງທາ່ ນດວ້ ຕາ່ ງໆ. ພວກເຮົາຈະໃຊ ້ພວກເຮົາຈະເກັບຕ ົວຢາ່ ງເລືອດຈາກປາຍນິວ້ ຍເຂັ້ມເຈາະທີ່ ປັດສະຈາກເຊືອ້ ມື-ÁìÉ¸-µº©-Ã¦È-Á°È−-À¥É¨-À²ˆº-ê¿-¡¾−-®‰¤´½ªò. ເຊິ່ ງປະລິມານ
ເຈຍຊ້ ັບເອົ າເລືອດຂອງທາ່ ນຈາກບາດນອ້ ຍໆຢູປ່ າຍນິວທີ່ ພວກເຮົາຕອ
ບເລືອດທັງໝ ົດຈະຖືກປະຕິບ ັດໂດຍ
ັ້້ ງການຢູລ່ ະຫວາ່ ງ 0.05ml ຫາ 0.2ml. ຂນຕອນການເກັພະນ ັກງານເຕັ ກນິກທີ່ ໄດຮົ້ ວັ້ .້ ພວກເຂົາຈະຕິດແຜນ້ ັບການຝຶກອ ົບຮ ົມຈາກການຄນຄ້ າຄງນີ່ ຕິດບາດທີ່ ສະອາດບ ົນ້ ພະຍາດຕາ່ ງໆໃນພາຍຫຼ ງັ . ພວກເຮົາຈະໃຊເ້ ຂັມ້ ເຈາະເລືອດອ ັນໃໝ ່ ບໍ່ ຊາໍ້ບາດແຜຂອງທາ່ ນ ເພື່ ອປອ້ ງກ ັນການຕິດເຊືອກ ັນໃນແຕຄ
່ ົນ.

76 Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR5. ¡¾−-¯ö¡-¯Éº¤-£÷É´-£º¤-£¸¾´-À¯ñ−-¦È¸−-ªö¸ -Áì½ »ñ¡¦¾£¸¾´-ìñ®-¢º¤-°øÉ-À¢í¾-»È¸´້ ນພວກເຮົາຈະເກັບ»ñ¡¦¾ຂໍມ
ູ ຂອງທາ່ ນ ແລະ ເດັກໄວຢ້ າ່ ງປອດໄພ´, ເປັນຄວາມລ ັບ ແລະ- ¥½®ÒÄ©É-®ñ−êô¡-§ˆ-¢º¤-êÈ¾−-

້ ນÃ¦ú-. ນອກຈາກພະນ ັກງານ-ທີມງານຄນຄ
ູ ສວ
ົ້ ວ
້ າແລວ້ ບໍ່ ມີໃຜທີ່ ຈະສາມາດເຂົ້າເຖິງຂໍມ່ ນຕ ົວຂອງທາ່ ນໄດ.້
6. ສິດໃນການປະຕິເສດ ຫຼື ຖອນໂຕ້ ອງທາ່ ນແມນເປັ
ການເຂົ້າຮວາ້ ຄງນີົ້ັ້ ຂ່ ມໃນການຄນຄວ່ ນໄປຕາມຄວາມສະມ ັກໃຈ. ມ ັນແມນສິ່ ດທິຂອງທາ່ ນໃນການ
ເລືອກທີ່ ຈະເຂົ້າຮວາ້ ຈະບໍ່ ສ່ງົ ຜ ົນສະທອົ້່ ມ ຫຼື ບໍ່ ເຂົ້າຮວ
່ ມ. ການປະຕິເສດເພື່ ອເຂົ້າຮວ່ ມການຄນຄວ້ ນຫຍ ັງເຖິງທາ່ ນ.

້ົທາ່ ນສາມາດຢຸດການເຂົ້າຮວາ້ ຄງນີຸ ເວລາຕາມທີ່ ທາ່ ນປະສ ົງ. ການຢຸດເພື່ ອເຂົ້າຮວັ້ ໄ້ ດທ່ ມໃນການຄນຄວ້ ກ່ ມໃນຊວ້ ງໃດຊວາ້ ກໍ່ ຈະບໍ່ ສ່ງົ ຜ ົນສະທອ
ົ້້ ງໜຶ່ ງຂອງການຄນຄວ້ ນຫຍ ັງເຖິງທາ່ ນອີກເຊັ່ ນກ ັນ.

້ ມນຂໍ້ ນຂາ້ ງເທິງນີແູ ກຽ່ ວກ ັບການຄນຄົ້ ວັ້ ້ ແລະ ພວກເຮົາກາລໍ ັງເຊີນທາ່ ນເພື່ ອເປັນສວົ້ ວ່ ມ້ າຄງນີ່ ນໜຶ່ ງຂອງການຄນຄ
້ າ.

້ ອ
ກະລຸນາຕິດຕໍ່ ສະມາຊິກທາ່ ນໃດທາ່ ນໜຶ່ ງຂອງທີມງານຄນຄົ້ ວ້ າຖາ້ ຫາກມ ີຄ ໍາຖາມ ຫຼື ຂໍຂ້ ງໃຈຕາ່ ງໆ.
້ົ ວບຸກຄ ົນທີ່ຮ ັບຜິດຊອບໃນການສຶກສາຄນຄ້ າ.
Annoh Xeuatvongsa MD, PhD

Masahiko Hachiya, MD, PhD

ຫົວໜາ້

ຂະແໜງການບໍລກິ ານຊຽ່ ວຊານ, ພະນ ັກງານ

ພະແນກສ ັກຢາກ ັນພະຍາດເປີດກວາ້ ງ (EPI)ພະແນກຮວ່ ມມືການແພດສາກ ົນສູນສຸຂະພາບແມ ່ ແລະ ເດັກສູນກາງການແພດ ແລະ ສຸຂະພາບໂລກແຫງ່ ຊາດກະຊວງສາທາລະນະສຸກແຫງ່ ສປປລາວຍີ່ ປຸ່ນ
1-21-1 Toyama, Shinjuku, Tokyo,
162-8655, JAPANTel +81-3-3202-7181,
Fax +81-3-3205-7860
E-mail; m-hachiya@it.ncgm.go.jp

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 77

<ແບບຟອມຕ ົກລ ົງຍິນຍອມສ ໍາລ ັບພໍ່ ແມ>່້ ນ້ ນ່ ັ ກາ່ ວ ແລະຂາ້ ພະເຈົ້າໄດອູ ທີ່ ໄດກູ ດງ້ າ່ ນຂໍມ້ າ່ ວມານນັ້ ຫຼື ໄດຮ້ ັບຮູ.້ ຂອ້ ຍໄດມ້ ີໂອກາດຖາມຄ ໍາຖາມກຽ່ ວກ ັບຂໍມບ ັນຫາຕາ່ ງໆທີ່ ຂາ້ ພະເຈົ້າໄດຖ
ຖື ຕອບດວ້ າມແມນໄດ່້ ກ້ ຍຄວາມເພິ່ ງພໍ ໃຈຂອງຂາ້ ພະເຈົ້າ. ສະນນັ້ ຂາ້ ພະເຈົ້າ ຍິນຍອມສະມ ັກໃຈເຂົ້າເປັນຜູເ່ ຂົ້າຮວາ້ ຄງນີ
ົ້ັ້ ້ ແລະ ພອິ ໃນການປະຕິເສດເພື່ ອຖອນ່ ມໃນການຄນຄວ້ ມທັງເຂົ້າໃຈວາ່ ຂາ້ ພະເຈົ້າມີສດ້ ຕໍ່ ລະບ ົບການປິ່ ນປົວ-ຮ ັກສາສຸ¢½-ພາບຂອງ
ໂຕຈາກການຄນຄວາ້ ໃນເວລາໃດກໍ່ ໄດໂ້ ດຍທີ່ ບໍ່ ມ ີຜົນກະທົບໃດໆທັງສິນ
ົ້ຂາ້ ພະເຈົ້າ.
ຊື່ ຂອງຜູເ່ ຂົ້າຮວ່ ມລາຍເຊັ ນຂອງຜູເ່ ຂົ້າຮວ່ ມວ ັນທີ (ວ ັນທີ/ເດືອນ/ປີ)_______________________________________________

ຖາ້ ຫາກບໍ່ ສາມາດອາ່ ນ ຫຼື ຂຽນພະຍານທີ່ ເປັນໂຕແທນໃຫຜື ໜ ັງສືຈາເປັ
ໍ ນຕອ
້ ກ
ູ່ ກ
້ ງເຊັ ນຕາງໜາ້ (ຖາ້ ເປັນໄປໄດ,້ ຕ ົວພະຍານຄວນໄດຮ້ ັບການເລືອກຈາກຜູ່້ ກ ັບທີມງານຄນຄວສະມ ັກເຂົ້າຮວ
າ້ ). ຜູສົ້່ ມທີ່ ກືກໜັງສື ແລະ ຫຼີກລຽ່ ງການມີສວ່ ນພົວພັນໃດໆທັງສິນ່ ະມ ັກເຂົ້າຮວ່ ມທີ່ ກືກ້ ໂປ້ມ ືເພື່ອເປັນຫຼກ
ໜັງສື ຄວນຈາລາຍນິວໍັ ຖານເຊັ່ ນກ ັນ.

ຂາ້ ພະເຈົ້າໄດເ້ ປັນພະຍານໃນການອາ່ ນຢາ່ ງລະອຽດຂອງແບບຟອມຍິນຍອມຫາຜູທ່ ມ,່ ່ ີມີຄວາມເໝາະສ ົມເປັນຜູເ່ ຂົ້າຮວ້ ອແລະ ຜູກ່ ຽ່ ວໄດມ້ ໂີ ອກາດຊ ັກຖາມຄ ໍາຖາມ-ຂໍຂ້ ງໃຈຕາ່ ງໆ. ຂາ້ ພະເຈົ້າຂໍຢືນຍ ັນວາ່ ຜູກ່ ຽ່ ວໄດໃ້ ຫຄ້ ວາມຍິນຍອມຢາ່ ງອິດສະຫຼ ະ.
ຊື່ ຂອງຜູເ່ ຂົ້າຮວ່ ມລາຍເຊັ ນຂອງຜູເ່ ຂົ້າຮວ່ ມວ ັນທີ (ວ ັນທີ/ເດືອນ/ປີ)_______________________________________________

ຂາ້ ພະເຈົ້າໄດອ້ າ່ ນ ຫຼື ເປັນພະຍານໃນການອາ່ ນຢາ່ ງລະອຽດຂອງແບບຟອມຍິນຍອມຫາຜູທ່ ່ ີມີຄວາມເໝາະສ ົມເປັນຜູເ່ ຂົ້າ້ ອຮວ່ ມ, ແລະ ຜູກ່ ຽ່ ວໄດມ້ ໂີ ອກາດຊ ັກຖາມຄ ໍາຖາມ-ຂໍຂ້ ງໃຈຕາ່ ງໆ. ຂາ້ ພະເຈົ້າຂໍຢືນຍ ັນວາ່ ຜູກ່ ຽ່ ວໄດໃ້ ຫຄ້ ວາມຍິນຍອມຢາ່ ງອິດສະຫຼ ະ.
ຊື່ ຂອງຜູເ່ ຂົ້າຮວ່ ມລາຍເຊັ ນຂອງຜູເ່ ຂົ້າຮວ່ ມວ ັນທີ (ວ ັນທີ/ເດືອນ/ປີ)_______________________________________________

ສ ໍາເນົາແບບຟອມການຍິນຍອມໄດມ
່ ມ 1 ສະບ ັບ້ ອບໃຫຜ້ ເູ່ ຂົ້າຮວ

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- ö©-Â£¤-»È¾¤-®ö©-ì¾¨-¤¾− Ã−À©õº−´ò«÷−¾2013¡È¼¸-¡ñ®¡¾−-¦ô¡¦¾-ºñ©ª¾-¡¾−-ªò©-À§œº-ºñ¡-À¦®-ªñ®-§½−ò© ®ó Ã− ¦¯¯ ì¾¸-. ®ö©-ì¾¨-¤¾−¦½ÍÐ®-¦÷©-êÉ¾¨-¦½®ñ®-£ö®-«É¸−-¥½-ÁìÉ¸-¦ö´®ø−²¾¨-Ã−-´Ò-Å−š®ö©-¦½ÍÐ®-−š-Ä©É-«õ¡-¡½¡¼´-Â©¨:©ë. À£−-−ò¥ò Â£-´¾-©½, MD, MPH©ë. Âê-Â´-´ò £òª¾-´÷ë½, MD, MPH©ë. ´¾-§¾-»òÂ¡½ »¾-¥ò-µ½, PhD, MD, MPH (°øÉê†-À¯ñ−-ªí−ªð-Ã−-¡¾−-À»ñ©¡¾−-¦ô¡¦¾-£í−£¸É¾-)¡¾−-¦ô¡¦¾-£í−£¸É¾-Ã−-£˜¤-−š-Á´È−-Ä©É-»ñ®-êô−-§È¸¨-ÀÍõº-¥¾¡ສູນການແພດ

ແລະສຸຂະພາບໂລກແຫງ່ ຊາດຍີ່ ປຸ່ນ,êô−§È¸¨-À¹ùõº ¦½®ñ®-Àì¡êó 22-Œ7¢ð-¦½¹¤¸−-ìò-¢½-¦ò©-êñ¤-Ïö©-Ã−-Àº¡½¦¾−-¦½®ñ®-−š.

ສູນການແພດ ແລະ ສຸຂະພາບໂລກແຫງ່ ຊາດຍີ່ ປຸ່ນ1Œ21Œ1 Âê-µ¾-´¾, §ò−-¥÷¡÷,-Âª-¡¼¸ 162Œ 8655, ¯½-Àê©-¨†¯÷È−-Âêì½¦ñ® 81-Œ3Œ-3202Œ-7181-Á³ñ¡ 81Œ-3Œ-3205Œ-7860
http://www.ncgm.go.jp/

Technical Report vol.05 Hepatitis B Prevalence Survey in Lao PDR 83

Technical Report vol.05

Hepatitis B Prevalence Survey in Lao PDRThis report was prepared by:

Tomomi Kitamura, MD, MPH
Koji Wada, PhD, MD, MSc

Kenichi Komada, MD, MPH

Masahiko Hachiya, PhD, MD, MPH (principal investigator)
This work was supported by The Grant of National Center
for Global Health and Medicine (22-7).

National Center for Global Health andMedicine, Japan

Bureau of International Medical Cooperation

1-21-1 Toyama, Shinjuku, Tokyo 162-8655, JAPANTel : 81-3-6228-0327 / Fax : 81-3-3205-7860
info@it.ncgm.go.jp
www.ncgm.go.jp/
Issued in March, 2014©2014 National Center for Global Health and Medicine, Japan All Rights Reserved.