J Primary Prevent

DOI 10.1007/s10935-013-0333-0

ORIGINAL PAPER

Getting the Shots: Methods to Gain Adherence

to a Multi-Dose Vaccination Program for Inner City,
Drug-Involved Prostitution Communities
Giffin W. Daughtridge • Timothy W. Ross •

Paola A. Ceballos • Carmen E. Stellar

Ó Springer Science+Business Media New York 2013

Abstract Street-based sex-work and poly-substance
drug use, coupled with low vaccination rates and
limited utilization of the mainstream health care
system, put the sex worker communities of Bogotá’s
city center at extreme risk of infection with the hepatitis
B virus (HBV). Vaccination is critical to maintaining
low prevalence of the disease and low incidence of new
cases, yet the floating and inconsistent nature of
Bogotá’s drug-involved female and transsexual prosti-
tution communities make it difficult to complete a
G. W. Daughtridge
Perelman School of Medicine at the University of
Pennsylvania, 3620 Hamilton Walk, Philadelphia,
PA 19104, USA
G. W. Daughtridge (&)
2400 Chestnut St. Apt. 1704, Philadelphia, PA 19103,
USA
e-mail: gdaug@mail.med.upenn.edu
3-dose vaccination program. Between December 2011
and March of 2012, the Fénix Foundation collaborated
with the Bogotá Health Department to deliver free HBV
vaccines to this vulnerable population. This paper
outlines methods used in the vaccination program to
generate a 37.7 % adherence rate, significantly higher
than that previously reported for HBV vaccination
programs also targeting marginalized populations. This
program’s practices are based on the Fénix peer leader
method, and are offered as a model that can be applied
to other health interventions operating in analogous
contexts, with similarly high-risk populations.
Keywords Hepatitis B  Vaccination 
Prostitution  Peer leaders  Health intervention
adherence  Street communities
Introduction

T. W. Ross
In Colombia, prostitution is a legally permitted activity
Fundación Social Fénix, Carrera 3a, No. 21-46,
Apto. 2604-A, Bogotá, Colombia for people over the age of 18. Sex workers are required
e-mail: timothy@etb.net.co to receive intermittent health assessments to identify
and treat sexually transmitted infections (STI). How-
P. A. Ceballos
ever, street-based sex workers who are unaffiliated
Universidad de La Salle, Carrera 5 N. 59A 44, Bogotá,
Colombia with brothels are largely unregulated, represent a high-
e-mail: paoceballosquiroga@gmail.com risk population with a variety of unmet health needs,
and were the primary target of an STI vaccination
C. E. Stellar
program. A 2009 study conducted in Bogotá, Colom-
Weill Cornell Medical College, 1300 York Avenue,
New York, NY 10065, USA bia, found that 24 % of 514 female sex workers (FSW)
e-mail: ces2010@med.cornell.edu described themselves as female street-based sex

123

workers (FSSW). Relative to sex workers who worked
in bars, brothels, and clubs, these women reported a
greater number of clients per week, and were typically
younger, more likely to use illegal drugs, less likely to
use a condom during vaginal sex with clients, more
likely to have a syphilis infection, and more likely to
belong to a lower socio-economic stratum (Mejia et al.,
2009). FSW under the age of 18, whether street-based or
in clandestine brothels, are at a particularly high risk of
disease (Pinzón-Rondón et al., 2009).
Due to frequent engagement in high-risk activities,
female and transsexual street-based sex workers are in
great danger of contracting and transmitting pathogens
through infected bodily fluids. High-risk behaviors
endemic to this population include: unprotected sexual
intercourse with multiple partners, extensive drug use
resulting in bio-fluid contact, tattoos and piercings
using shared instruments, and physical transformation
operations performed by unlicensed amateur surgeons
(Gust, 1996; Lavanchy, 2004). It is therefore espe-
cially important to target this population in vaccina-
tion campaigns aimed at controlling viral disease.
The transmission of hepatitis B via infected blood
or other bodily fluids is a pressing global health
problem and a particular concern for individuals
involved in prostitution. About 350 million people
worldwide suffer from chronic hepatitis B infection,
and the virus is estimated to be 50–100 times more
transmissible than HIV (WHO, 2012c).
As Mast et al. (2006) have noted, ‘‘Hepatitis B
vaccination is the most effective measure to prevent
hepatitis B virus (HBV) infection and its consequences,
including cirrhosis of the liver, liver cancer, liver failure,
and death’’ (p. 1). The vaccine has been available since
the early 1980s (Francis et al., 1982; Szumeness et al.,
1980). Studies have shown that seroprotection rates—
defined as an antibody to hepatitis B antigen (anti-HBs)
level of C10 mIU/mL—are achieved by at least 90 % of
patients receiving three doses of the vaccine (Adkins &
Wagstaff, 1998; Hérnandez-Bernal et al., 2011).
Colombia initiated universal neonatal vaccination
against hepatitis B in 1994 (Mayor Mora et al. 2010),
but because the Colombian minimum legal age for
prostitution is 18, almost no adult sex workers had
received the full course of the vaccine when our
vaccination program was initiated in 2011. The
necessity of a completed hepatitis B vaccine course
for this population was demonstrated by a Venezuelan
study conducted in 2003, which found that 13.8 % of
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J Primary Prevent
sex workers sampled tested positive for anti-HBc
serologic markers, indicating previous or ongoing
infection with hepatitis B. Based on these results, the
authors recommended that the Venezuelan Ministry of
Health initiate programs to vaccinate sex workers
against hepatitis B (Camejo et al., 2003). A similar
catch-up immunization course for the sex worker
population in Bogotá is also necessary. Unfortunately,
it is very difficult to successfully implement such a
program due to real and perceived obstacles to
accessing healthcare for marginalized populations.
Colombia’s most impoverished and indigent pop-
ulations are eligible for a government-subsidized form
of social security, which covers emergency and
preventive health services for low-income citizens,
including free vaccines (Caprecom, 2013). Many
street-based sex workers have difficulty navigating
the enrollment process, while others possess some
form of health insurance, but remain infrequent
consumers of healthcare services. Mejia et al. (2009)
estimated that over 60 % of female sex workers in
Bogotá have health insurance, and noted that even
insured sex workers seemed to underutilize available
health services. It is possible that FSSW and trans-
sexual sex workers have lower levels of health
insurance as they are more socially excluded, but
further research is needed in order to determine how
discrimination and self-exclusion interact to produce
low levels of healthcare-seeking behavior in this
particularly vulnerable population (Dror & Jacquier,
1999; Jeal & Salisbury, 2004).
In addition to barriers to accessing the healthcare
system, completing the hepatitis B three-dose vaccine
schedule is problematic in an unstable and floating
population with high rates of poly-substance abuse,
weak social support structures, frequent changes in
locations of work and residence, and poor capacity to
project into the future and to keep appointments.
Consequently, we needed to develop new contact and
communication techniques to gain maximum adher-
ence to the vaccination schedule.
This paper demonstrates that principles of partic-
ipatory investigation and peer led interventions (Ritt-
erbusch, 2011; Valente & Pumpuang, 2007; Wiebel,
1993) can be used to overcome barriers to healthcare
access for high-risk groups. The strategies outlined for
maintaining contact can be replicated or improved in
future prophylactic programs for HBV and other
infections. They can also be applied to other health
J Primary Prevent
interventions such as regular pap smears and HIV
testing.
Methods
Informal interviews—conducted by the Fénix organi-
zation in September of 2011, with a convenience
sample of approximately 30 people recruited by chain
referral (sometimes referred to as snowball sam-
pling)—suggested that less than ten percent of sex
workers in central Bogotá had completed HBV
vaccinations. Fénix is a non-governmental organiza-
tion with which all four authors are affiliated. It has
worked with drug-involved prostitution communities
since 2008 to promote enhanced healthcare-seeking
behavior, self-empowerment, and opportunities for
exiting prostitution. Fénix supports peer leaders affil-
iated with the organization, and as yet unaffiliated
FSWs, through peer-led community outreach. Peer
leaders make their own transitions from prostitution
towards vocational training and professional educa-
tion by first learning to act as harm reduction health
educators for other FSWs and then to identify, engage,
and train new peer leaders from among them. To
address the low number of HBV immunized sex
workers, Fénix requested HBV vaccines from the
Bogotá Secretary of Health and proposed a collabo-
rative campaign for free application in two areas
within key prostitution zones.
In December of 2011 and January and March of
2012, a vaccination team from a local hospital
administered a three-dose (20 lg/mL) course of the
Bharat Biotech Revac-B ? HBV vaccine. The vac-
cines were applied over two days in each of these
months at El Refugio and La Mariposa square. They
were also offered daily in a local hospital for those not
attending the vaccination days. Participants in the
three-dose vaccination campaign were recruited
through peer network contacts and chain referrals.
Contact details of all who attended one of the two
vaccination days in December were listed, and their
compliance with subsequent doses was tracked by
means of a comprehensive database.
Peer Leader Methodology
Existing peer networks within the sex work community
are central to Fénix0 outreach methods and to the
recruitment and retention of participants in this vacci-
nation program. Core peer leaders are engaged through
the generation of mutual relationships, which encour-
age the personal development of peer leaders, as well as
their involvement in advocacy for their street-based
social groups (e.g. distribution of condoms or invita-
tions to healthcare activities). The work of peer leaders
has a dual purpose: to help reduce risks and to generate
motion towards positive decision-making.
The relationships between Fénix and street popu-
lations are built up through the work of four kinds of
peer leaders:
1 ‘Embedded’ Peer Leaders are still enmeshed in
prostitution but act as key informants and infor-
mation diffusers.
2 ‘Transitional’ Peer Leaders are trying to reduce
involvement in prostitution, take Fénix-run train-
ing classes, and function as models for others.
3 ‘Exited’ Peer Leaders have left prostitution, found
other sources of income, and are usually complet-
ing their education. They act as educators, gate-
keepers, mentors, and models.
4 ‘Congruent’ Peer Leaders study health and social
care professions, but come from similar back-
grounds of poverty, neglect, dysfunctional or
absent families, social exclusion, and sometimes
sexual abuse or exploitation, giving them the
ability to identify with and mentor street youth.
Embedded peer leaders are initially identified
through ‘‘staff selection,’’ by which potential leaders
are recognized through community observation, and
‘‘judge’s ratings,’’ whereby community members
themselves identify individuals they believe to be
leaders (Valente & Pumpuang, 2007). Selected leaders
may attend any number of 60–80 min workshops,
which cover topics ranging from the prevention,
detection, and treatment of STIs, to opportunities for
education and job training. Peer leaders who demon-
strate interest are invited to attend workshops focused
on outreach intervention methods, and may also be
offered psychotherapeutic support through the Fénix
network of clinicians. As self-efficacy and capacity for
positive action advance, the peer leaders in turn begin
to teach their friends and propose new candidates for
leadership work. Natural diffusion of information on
opportunities for change and possibilities for exiting
prostitution encourage still others to volunteer for
leadership roles.
123

Throughout the course of the vaccination program,
one ‘transitional’ and one ‘congruent’ peer leader,
who were both closely affiliated with the organization,
worked directly with the study’s authors. The effec-
tiveness of this nuclear team was enhanced by ten
‘embedded’ and ‘transitional’ peer leaders who were
very supportive of the program’s goals and motivated
to assist with the recruitment and retention of partic-
ipants. Members were able to exploit their existing
peer networks to further circulate the message of
health maintenance and disease prevention. In one
case, an approximately 35-year-old ‘embedded’ peer
leader received a dose on the first vaccination day and
was then asked to look for friends to relay what she had
learned about hepatitis B. She returned shortly with
another FSW and was delighted to be congratulated.
During the day, she arrived three more times with one
to three others, explained the procedure, shepherded
them into the vaccination tent, and introduced them to
the coordinator.
Collaboration with Other Organizations
Fénix has a strong peer leader network, but lacks
several necessary components for carrying out an
effective vaccination program. The three most critical
are the following: vaccines, healthcare professionals,
and a safe and comfortable space near the participants’
work place in which to deliver the vaccinations. The
authors identified these needs prior to the onset of the
program, and were able to address all three through
meetings with the Bogotá Health Department and El
Refugio convent.
The Bogotá Secretary of Health coordinates, con-
trols, and funds all public hospitals and health programs
active in the capital. The director and senior manage-
ment are political appointees, who change with each
four-year mayoral term, limiting long term policy
planning. With regards to our program, the Health
Department had the vaccines and the healthcare
professionals to deliver them, but it lacked the respect
of, and close contact with, the target population. Fénix,
on the other hand, lacked vaccines but enjoyed close
links with the prostitution community. The collabora-
tion resulted in participants who were educated and
recruited by Fenix0 peer network and vaccinated using
the supplies and nursing staff of the Health Department.
El Refugio is a Catholic convent conveniently located
on a corner that abuts three of the main streets frequented
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J Primary Prevent
by sex workers in Bogotá, especially male-to-female
transsexual sex workers. They regularly offer their
facilities for HIV testing, pap smears, meetings, and
other services. Due to the overlapping missions of the
Fénix organization and El Refugio, the two frequently
partner on outreach activities. Fénix provides the peer
leader network, which facilitates access to the popula-
tions on the street. El Refugio offers its ideal location and
reputation as a comfortable center for free healthcare,
psychological support, and—especially important in a
Catholic country—spiritual comfort. The participation
of nuns in action with marginalized groups helps reduce
their sense of exclusion and appears to provide important
support and acceptance in a country where Catholic
social values can contribute to stigmatization (Bindel &
Kelly, 2003). This religious order, along with two others,
provides a range of services that includes schooling,
vocational training, and employment, and forms part of a
network of organizations defending prostitution com-
munities. This has led to conflicts with the Catholic
hierarchy, particularly over condom advocacy.
Initial Information Dissemination
Six weeks before the first vaccination day, outreach
teams composed of peer leaders and the study authors
began disseminating information on hepatitis B. Peer
leaders helped design pamphlets and flyers featuring
strong imagery, vernacular language, and alliterative,
memorable phrasing. These materials were utilized
during small group workshops of one to four individuals
each, usually lasting 5–10 min. The workshops, gener-
ally conducted in brothels or on street corners, focused
on the prevalence of the disease, its risk factors and
consequences, and vaccination as the most effective
prevention method, while stressing consistent condom
use. We involved each workshop participant by asking
questions to generate reflection on risk, asking for
feedback on the most important information, and/or
inviting an individual to explain key points to newcom-
ers. Communication techniques alternated humor,
clowning, and dramatic theatricality with seriousness
and evidence. This style allowed us to engage the
population without minimizing the gravity and lethality
of the disease. In the week preceding the first vaccina-
tion day, we added dates, times, and locations of the
vaccination sessions to printed educational materials.
We also intensified the frequency of street outreach.
J Primary Prevent
Primary Vaccination Days (13th and 14th
of December, 2011)
We offered vaccines from 10 AM to 2 PM, before the
increased frequency of prostitution activities and drug
use would hinder attendance. Peer leaders were among
the first to receive the vaccine. We then asked them to
find other potential participants to bring to the vaccina-
tion locations. We gave each person who received a
vaccination an immunization card that recorded the dates
of the initial and upcoming doses. We recorded extensive
contact information in a database, including the follow-
ing: legal name, ‘‘chapa’’ or street name, identity card
number, home telephone and address, work location, cell
phone, and names and phone numbers of two additional
contacts (e.g., family or close friends). Each person also
received a printed slip with the dates of the second and
third doses. Additionally, a professional outreach worker
talked to each one about the importance of receiving all
three doses of the HBV vaccine to achieve maximum
protection. Finally, we asked each participant to spread
the word to friends and, when possible, to bring in
others—a key tactic in the recruitment strategy.
Promotion for Second Vaccination Days
We continued street outreach by distributing educa-
tional materials in vernacular language and hosting
mini-workshops. The list of names and work locations
of those who had received the first dose was consulted
each time, so that outreach team members could locate
each participant. Additionally, a peer leader familiar
with all the participants called each one the night
before the vaccination session. If individuals could not
be contacted using primary phone numbers, we called
secondary contacts. We spoke with the majority of our
participants (or a secondary contact) and reminded
them to attend. We recorded calls in the database so
that those who were not reached could be called again
the next morning. We asked the individuals we were
able to contact to bring friends, especially if they had
attended the first vaccination.
Second Vaccination Days (17th and 18th
of January, 2012)
The first vaccination days’ methods were repeated.
Leaders were vaccinated and then recruited others,
volunteers updated participants’ vaccination cards,
and a volunteer or outreach worker talked to each
participant about the importance of completing the
entire set of vaccinations. Participants who had lost
their cards were located in the database and issued a
new card. Two hours into the 4-h vaccination period,
we used the database to call every person in our
original sample who had not yet arrived for the second
dose. If individuals not included in the original
program arrived through peer contacts and asked to
be vaccinated, we complied unless there was strong
evidence that they were not genuinely members of the
target population. We recommended that they go to
the nearby Hospital Samper Mendoza for subsequent
doses to complete their vaccination plan.
Inter-Vaccination Phase
In the two months between the second and third
vaccinations, we used the database to individually
contact the people who had not come for their second
dose. We informed them that they should go to the
Hospital Samper Mendoza to obtain their vaccine. We
called the phone numbers they had given us, called
their additional contacts as needed, searched for them
on the streets near their home and work locations, and
asked other sex workers if they knew the whereabouts
of those on our list.
We quickly discovered that most sex workers were
unwilling to go to the hospital alone. The most
common explanations for resistance were the distance
to the hospital, their desire not to lose clients, and their
reluctance to leave the apparent security of their
circumscribed territory. We therefore arranged meet-
ing times within the prostitution zones and accompa-
nied groups of participants to the hospital. In the
weeks leading up to the final vaccination day, we
applied the same protocol as that used prior to the
second dose.
Third Vaccination Days (13th and 14th of March,
2012)
We followed the same procedure used on the previous
vaccination days. The authors had individual conver-
sations with those who received their third dose to
congratulate them on their accomplishment, to encour-
age them to continue making positive health decisions,
and to urge their peers to do the same.
123

Follow-Up
After the third vaccination day, we made efforts to
ensure that individuals who had received only one or
two doses of the HBV vaccine went to the hospital for
their subsequent vaccinations. Since most would not
go to the hospital alone, we hired a driver and
contacted everyone who had not received the three
doses. All were asked to meet the following day in a
specified location. From there, we drove them to the
Hospital Samper Mendoza for the next dose.
Results
Altogether, 122 individuals received the primary dose
of the hepatitis B vaccine on the first days of the
immunization series, including some sex workers’
partners. The vaccines were delivered at two locations:
El Refugio (December 13th) and La Mariposa
(December 14th). Promotion for the vaccination day
at El Refugio gave particular emphasis to male-to-
female transsexual prostitutes, as anal sex increases
the risk of acquiring viral infections, and over one-
third of participants at El Refugio were transsexual
(Hadler & Margolis, 1993). ‘La Mariposa,’ officially
‘Plaza San Victorino,’ is a plaza where large numbers
of street-based FSW look for clients. The sex workers
in La Mariposa are predominantly younger, more
recent entries into prostitution, and are less institu-
tionalized in the sex work subculture. Some maintain
other income-generating activities, and resort to
prostitution only part-time or at moments of crisis.
La Mariposa square is frequented by a number of
young, female-to-male transgender people, but almost
no male-to-female transsexuals, in contrast to the
population working near El Refugio. Fénix has done
extensive intervention work in the areas around both
El Refugio and La Mariposa. The resultant trust-based
relationships allowed us to recruit a large proportion of
this population to the initial vaccination days.
This vaccination program was not planned as a
study but as a public health intervention aimed at
vaccinating extremely high-risk groups against HBV.
Between El Refugio and La Mariposa, the ages of
participants ranged from 14 to 62, with an average age
of approximately 23. Though it is possible that some
of the participants between the ages of 14 and 18 had
already received the vaccine at birth, there was no
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J Primary Prevent
additional harm in applying a second HBV vaccina-
tion (WHO, 2009). Furthermore, exact birth years
could not be determined as the participants frequently
lie about their age in order to attract clients, and the
authors determined that the benefits of vaccinating
those interested in taking a proactive stance on their
health outweighed any risk of re-vaccinating them.
Aside from age, which was recorded in the nurses0
identification log for each participant vaccinated, we
were not concerned with recording demographic data
for people receiving any dose of the vaccine; rather,
we focused on gathering information that would help
recruit and maintain contact with participants.
In total, 38 % of the individuals who received the first
dose of the vaccine on either December 13th or 14th
completed the program and received the second and third
doses of the vaccine, and 67 % received at least two of the
three doses. At El Refugio, 42 % of the participants who
received their first dose were completely vaccinated, and
65 % received at least two of the three doses. In La
Mariposa, 32 % of the participants received all three
doses, while 70 % received at least two.
Seventy-one people not in the original cohort came
to either the second or third vaccination days to
receive their first dose of vaccine. Because we were
most interested in creating an intervention methodol-
ogy that would elicit full program adherence, these
individuals were not included in the results reported
above. However, each participated in a mini-workshop
explaining the importance of receiving all three doses
of the vaccine in order to maximize the probability of
achieving seroprotection. Each person also received a
vaccination card, was asked for contact information,
and received a brochure or flyer with educational
material on hepatitis B along with condoms and
lubricants. Finally, we gave these individuals exact
instructions on how to find the local hospital, and
advised them to ask for their second and third doses at
this hospital on the appropriate dates. We did not have
the resources to follow up with each of these people in
the same manner as those enrolled in the program, and
this group was less likely than the original cohort to
return for subsequent doses.
Discussion
The threat of HBV infection presents a major public
health burden for unvaccinated populations. Mejia et al.
J Primary Prevent
(2002) reported that the HBV prevalence among
commercial sex workers in Bogotá was 7.5 %, and
informal interviews (see Methods) with peer leaders of
the Fénix Foundation indicated averages per individual
of 7 sexual encounters a day and 250 days of prostitu-
tion per year. First time encounters are usually pro-
tected, but the majority of workers are willing to have
unprotected sex with those who pay extra or with
‘‘special’’ clients with whom they have built a consistent
relationship. Anal and oral sex are seldom protected.
Hadler and Margolis (1993) suggested that there is a
1–3 % chance of HBV transmission per unprotected
sexual encounter in serodiscordant partners, with
women more vulnerable than men, and people in
prostitution, or with other STIs, at a substantially higher
risk. Furthermore, this is a public health concern for the
entire population, as many clients are married or have
other partners to whom they can retransmit the virus.
Reducing the risk of HBV transmission by targeting
high-risk groups with catch-up vaccination programs
should be a public health priority.
Unfortunately, the need for three separate doses of
the HBV vaccine, the floating nature of sex worker
populations, alcohol and drug intoxication, and the
instability of prostitutes’ social links make retention
for a complete vaccine course problematic in this
population. Exploratory research suggests that the
street-based sex worker populations of Bogotá’s city
center not only engage in heavy drug use, but also in
high-risk sex and frequent violence, and tend to suffer
devastating socioeconomic exclusion (Mejia et al.,
2009; Ritterbusch, 2011; Ross, 1992).
To address these challenges, an established method-
ology for recruiting high-risk populations to a multi-
dose vaccination program is necessary, but the current
literature on generating adherence in similar groups is
limited. Searches of Medline and LILACS, a database
for research in South and Central America, returned no
studies that reported adherence to an HBV vaccination
program for an impoverished high-risk population
engaged in drug use, sex work, or seeking care at an
STD clinic in Latin America. Nonetheless, the literature
that does exist illustrates the difficulty of ensuring
adherence to an HBV vaccination program. To give
context, a similarly sized HBV vaccination program for
at-risk populations seeking care at an STD clinic, though
not sex workers, recorded three-dose retention percent-
ages as low as 2.4 % (O’Rourke et al., 2001).
Adherence to an HBV vaccination schedule in
marginalized populations is a sparsely covered but
important area of research. However, the development
of an effective methodology for vaccinating high-risk
populations is necessary and has widespread implica-
tions, not only for the prevention of HBV, but also for
similarly dangerous infectious diseases whose global
prevalence can be primarily controlled through vac-
cination. The low cost, wide availability, and flexible
schedule of the HBV vaccine make it an optimal
candidate for any study seeking to develop method-
ologies aimed at increasing adherence to a multi-dose
vaccine schedule among high-risk populations.
The methods used to generate adherence in this
HBV program can be applied to future HBV vaccina-
tion efforts, as well as to diseases with similar risk
factors and even higher mortality rates in infected
persons, notably hepatitis C (HCV) and HIV. Accord-
ing to the WHO, these three diseases account for
almost 2.8 million deaths globally per year (WHO,
2012a, b, c). Though vaccines against HCV or HIV
have thus far proved elusive, candidate vaccines for
these diseases are currently in phase two (HCV) or
three (HIV) testing and would feature multi-dose
schedules similar to that for HBV (Gray & Michael,
2013; Houghton et al., 2013). This paper advances the
field of public health by presenting a methodology for
vaccinating a high-risk and hard-to-access population
not only against HBV, but also against HIV and HCV
if and when those vaccines come to market.
Impact and Future Outlook
The intended outcomes of this program were twofold:
to reduce the risk of HBV infection among central
Bogotá’s sex workers, and to develop a methodology
for future prophylactic efforts amongst high-risk
populations. By enrolling 122 members in the pro-
gram, and completing a three-dose schedule for 38 %
of them, a significant number of high-risk people
should now have protection against HBV infection.
Furthermore, Cassidy et al. (2001) showed that two
doses of the hepatitis B vaccine conferred seroprotec-
tion in over 95 % of adolescents vaccinated, whereas
one dose conferred seroprotection in 63.8 % of
adolescents vaccinated. Thus, the public health impact
of our study extends well beyond just those included in
the main program, as 193 at-risk people received at
123

least one dose of vaccine. This represents a substantial
public health benefit for the city of Bogotá.
In addition to reducing the risk of HBV infection, we
hope that other organizations can use this methodology
to replicate or improve upon our success in future
vaccination efforts. The methods described are pro-
posed for use by voluntary organizations, but official
health institutions could also make use of these and
similar techniques. Employing peer leaders to recruit
hard-to-reach populations for public health programs,
and combining the vaccination programs with other
outreach efforts, are two potentially productive areas
that could further the mission of governmental health
agencies and contribute to broader health-related
behavior changes in high-risk populations.
In addition to applying these methods, we suggest the
following improvements for generating adherence to a
multi-dose vaccination program in a high-risk popula-
tion. Proposals three and four are based on suggestions
by participants in post-vaccination workshops.
1 Use an accelerated vaccine schedule (i.e. 0, 10,
21 days). This schedule has been shown to gen-
erate sufficient protective antibody levels in adults
who receive the three doses of the vaccine
(Marchou et al., 1993; Rogers & Lubman, 2005).
Prostitution in Colombia is migratory, with many
individuals traveling to resorts during the high
season, touring small towns during the low season,
or fleeing conflicts in their home cities. Some
members of the Bogotá program were lost because
of moves away from the city, travel with a client or
partner, binge substance consumption, lost phones,
pregnancy, or other unexpected events whose
frequency could be decreased with shorter vacci-
nation schedules.
2 Follow up with late additions to the vaccination
program. The outreach efforts of our program
attracted 71 individuals who received their first
dose of vaccine on either the second or third
vaccination day. Because of limited resources, we
were unable to follow this population as effectively,
and they did not receive all the phone calls that the
original 122 participants did. These individuals
were therefore less likely to return for subsequent
doses, and hospital records indicate that none of
them went for follow-up doses on their own. In the
future, participants beginning their vaccination
schedule on the second or third vaccination day
123
J Primary Prevent
should be expected, and resources should be in
place to contact them using the same system as
those joining on the first vaccination day.
3 Incorporate improved tracking of demographic
information on the population receiving vaccina-
tions. This information is essential for detecting
trends in adherence to the vaccination program
within subsets of the target population. We
recommend recording information on the gender
identity, age, housing status, alternative employ-
ment, social support structure, drug and alcohol
use, mental health issues, number of clients, length
of time working in prostitution, condom use
patterns, history of STIs and vaccinations, and
distance to the vaccination site of each participant.
This information could then be used to better
allocate resources and to link specific peer leaders
to identified higher risk subpopulations.
4 Provide transportation to ensure participants’
arrival at vaccination sites. Although both sites
were located in or very near to the majority of the
participants’ places of work, the daily schedules of
these individuals are variable, and many doses were
missed because participants were unable to arrive at
the predetermined location on the designated day.
Participants cited a number of impediments to their
attendance, including tending to a client, taking care
of children, working another job, or being physi-
cally incapacitated by substance abuse. If transpor-
tation were available for participants who request it
during the reminder phone call, adherence might be
improved. Again, we found it much easier to
vaccinate on the designated days than to motivate
the participants to go to the local hospital and get
their doses independently, so every effort should be
made to decrease attrition at these events.
5 Vaccinate against other infectious diseases at the
same time. Having a large subset of a high-risk
population assembled and willing to participate in
a vaccination program provides a valuable oppor-
tunity for intervention. Influenza, hepatitis A, and
HPV vaccines could be useful additions to the
vaccination schedule in a future study. HPV
vaccines, though most effective when adminis-
tered before an individual begins sexual activity,
still can have prophylactic benefits due to the
variety of strains against which the vaccine can
protect (Adams et al., 2009; Brown et al., 2010;
J Primary Prevent
FUTURE II, 2007). Additionally, continuing to
develop this methodology provides groundwork
for the future inclusion of as yet undeveloped
vaccines for viral diseases such as HCV.
The high transmissibility of HBV and extreme
vulnerability to infection from sex work, drug use, and
associated risks make HBV vaccination for people in
prostitution a public health priority. Successful inter-
vention programs should assume the dual approach of
Fénix: working with vulnerable populations to identify
and address immediate risks, while generating momen-
tum towards future changes. In addition to HBV, other
STIs, violence, substance abuse, body transformations,
and trauma associated with upbringing and daily
environment consistently threaten the wellbeing of
sex workers (Mak et al., 2003). These realities
notwithstanding, qualitative research conducted in
Colombia suggests that members of this population
highly value their health as it is linked with the ability to
work and to generate income. STIs can represent an
‘‘economic disaster’’ for sex workers that they are keen
to avoid (Amaya et al., 2005, p. 70). An interest in the
preservation of health by sex workers, as well as
healthcare personnel, is an area in which the values of
both the consumers and the suppliers of preventive care
are well aligned, creating an opportunity for successful
health interventions when barriers to seeking and
providing care are addressed. Vaccination programs
represent an ideal form of intervention in this high risk
group as they serve multiple purposes: to reduce the
burden of preventable infection and its social costs, to
generate broader and self-sustaining changes in vul-
nerable groups that may reduce risk behaviors, and to
create pressures on authorities to provide effective, low-
cost, people-centered services.
Acknowledgments The authors gratefully acknowledge the
support of the Fulbright US Student Program.
References
Adams, M., Jasani, B., & Fiander, A. (2009). Prophylactic HPV
vaccination for women over 18 years of age. Vaccine,
27(25–26), 3391–3394.
Adkins, J. C., & Wagstaff, A. J. (1998). Recombinant hepatitis B
vaccine: A review of its immunogenicity and protective
efficacy against hepatitis B. BioDrugs, 10(2), 137–158.
Amaya, A., Canaval, G. E., & Viafara, E. (2005). Esti-
gmatización de las trabajadoras sexuales: Influencias en la
salud. Colombia Médica, 36(3, Supl 2), 65–74.
Bindel, J., & Kelly, L. (2003). A critical examination of
responses to prostitution in four countries: Victoria. Aus-
tralia: Child and Women Abuse Studies Unit, London
Metropolitan University.
Brown, B., Carcamo, C., Blas, M. M., Valderrama, M., &
Halsey, N. (2010). Peruvian FSWs: Understanding HPV
and barriers to vaccination. Vaccine, 28(49), 7743–7747.
Camejo, M. I., Mata, G., & Dı́az, M. (2003). Prevalence of
hepatitis B, hepatitis C and syphilis in female sex workers
in Venezuela. Revista de Saúde Pública, 37(3), 339–344.
Caprecom. (2013). Regimen Subsidiado. Retrieved from web-
site: http://www.caprecom.gov.co/portal/index.php?tipo
Doc=Regimen&idCategoria=49&idsubcat=38.
Cassidy, W. M., Watson, B., Loli, V. A., Williams, K., Bird, S.,
& West, D. J. (2001). A randomized trial of alternative two-
and three-dose hepatitis B vaccination regimens in ado-
lescents: Antibody responses, safety, and immunologic
memory. Pediatrics, 107(4), 626–631.
Dror, D. M., & Jacquier, C. (1999). Micro-insurance: Extending
health insurance to the excluded. International Social
Security Review, 52(1), 71–97.
Francis, D. P., Hadler, S. C., Thompson, S. E., Maynard, J. E.,
Ostrow, D. G., Altman, N., et al. (1982). The prevention of
hepatitis B with vaccine: Report of the Centers for Disease
Control multi-center efficacy trial among homosexual men.
Annals of Internal Medicine, 97(3), 362–366.
Future II Study Group. (2007). Quadrivalent vaccine against
human papillomavirus to prevent high-grade cervical lesions.
New England Journal of Medicine, 356(19), 1915–1927.
Gray, G. E., & Michael, N. L. (2013). Cautious optimism for
HIV vaccine science. Current Opinion in HIV & AIDS, 5,
367–368.
Gust, I. D. (1996). Epidemiology of hepatitis B infection in the
Western Pacific and South East Asia. Gut, 38(suppl 2),
S18–S23.
Hadler, S. C., & Margolis, H. S. (1993). Epidemiology of hep-
atitis B virus infection. In R. W. Ellis (Ed.), Hepatitis B
vaccines in clinical practice (pp. 141–157). New York:
Marcel Dekker Inc.
Hérnandez-Bernal, F., Aguilar-Betancourt, A., Aljovin, V., Arias,
G., Valenzuela, C., de Alejo, K. P., et al. (2011). Comparison
of four recombinant hepatitis B vaccines applied on an
accelerated schedule in healthy adults. Human Vaccines &
Immunotherapeutics, 7(10), 1026–1036.
Houghton, M., Law, J. L., & Tyrrell, D. L. (2013). An inacti-
vated hepatitis C virus vaccine on the horizon? Gastroen-
terology, 145(2), 285–288.
Jeal, N., & Salisbury, C. (2004). Self-reported experiences of
health services among female street-based prostitutes: A
cross-sectional survey. The British Journal of General
Practice, 54(504), 515.
Lavanchy, F. (2004). Hepatitis B virus epidemiology, disease
burden, treatment, and current and emerging prevention
and control measures. Journal of Viral Hepatitis, 11,
97–107.
Mak, R., Traen, A., Claeyssens, M., Van Renterghem, L., Leroux-
Roels, G., & Van Damme, P. (2003). Hepatitis B vaccination
for sex workers: Do outreach programmes perform better?
Sexually Transmitted Infections, 79, 157–159.
Marchou, B., Picot, N., Chavanet, P., Auvergnat, J. C.,
Armengaud, M., Devilliers, P., et al. (1993). Three-week
123

hepatitis B vaccination provides protective immunity.
Vaccine, 11(14), 1383–1385.
Mast, E. E., Weinbaum, C. M., Fiores, A. E., Alter, M. J., Bell,
B. O., Finelli, L., et al. (2006). A comprehensive immuni-
zation strategy to eliminate transmission of hepatitis B
virus infection in the United States: Recommendations of
the Advisory Committee on Immunization Practices (ACIP)
Part II: immunization of adults. Atlanta: Centers for Dis-
ease Control and Prevention (CDC).
Mayor Mora, A., Arias, A., Menjura, F. H., & Jaramillo Ángel,
L. F. (2010). Cruzada interminable por la niñez Colom-
biana. Historia del programa ampliado de inmunizaci-
ones—PAI—en Colombia 1979–2009. Bogotá: Ministerio
de la Protección Social, Organización Panamericana de la
Salud.
Mejia, A., Bautista, C. T., Leal, L., Ayala, C., Prieto, F., de la
Hoz, F., et al. (2009). Syphilis infection among female sex
workers in Colombia. Journal of Immigrant and Minority
Health, 11(2), 92–98.
Mejia, A.M., Montano, S.M., Vallejo, F., Prieto, F., Acosta, J.,
De La Hoz, F., Velandia, M.P., Sanchez, J.L., & Olson, J.G.
(2002). HIV-1, syphilis and hepatitis B virus prevalence
and risk factors among commercial sex workers, Bogotá,
Colombia. Poster Exhibit: The XV International AIDS
Conference: Abstract no. WePeC6251.
O’Rourke, K. M., Redlinger, T. E., & Steege, A. M. (2001).
Improving hepatitis B immunization among high-risk ado-
lescents: A low-cost intervention on the Mexico-United
States border. Revista Panamericana de Salud Pública, 9, 4.
Pinzón-Rondón, A. M., Ross, T. W., Botero, J. C., & Baquero-
Umaña, M. M. (2009). Prevalencia y factores asociados a
enfermedades de transmisión sexual en menores explota-
dos sexualmente en Bogotá, Colombia. Revista de Salud
Pública, 11(3), 468–479.
123
J Primary Prevent
Ritterbusch, A. (2011). A youth vision of the city: The socio-
spatial lives and exclusion of street girls in Bogotá,
Colombia. ProQuest ETD Collection for FIU. Paper
AAI3484191. http://digitalcommons.fiu.edu/dissertations/
AAI3484191.
Rogers, N., & Lubman, D. I. (2005). An accelerated hepatitis B
vaccination schedule for young drug users. Australian and
New Zealand Journal of Public Health, 29(4), 305–307.
Ross, T. (1992). Using and dealing on Calle 19: A high risk
street community in central Bogotá. International Journal
of Drug Policy, 13, 45–56.
Szumeness, W., Stevens, C. E., Harley, E. J., Zang, E. A.,
Oleszko, W. R., William, D. C., et al. (1980). Hepatitis B
vaccine: Demonstration of efficacy in a controlled clinical
trial in a high-risk population in the United States. New
England Journal of Medicine, 303(15), 833–841.
Valente, T. W., & Pumpuang, P. (2007). Identifying opinion
leaders to promote behavior change. Health Education &
Behavior, 34, 881.
WHO. (2009). Hepatitis B vaccines: WHO position paper-rec-
ommendations. Vaccine, 28(3), 589–590.
WHO. (2012a). Hepatitis B fact sheet no. 204. Retrieved from
website: http://who.int/inf-fs/en/fact204.html.
WHO. (2012b) Hepatitis C fact sheet no. 164. Retrieved from
website: http://www.who.int/mediacentre/factsheets/fs164/
en/index.html.
WHO. (2012c) HIV/AIDS fact sheet no. 360. Retrieved from
website: http://www.who.int/mediacentre/factsheets/fs360/
en/index.html.
Wiebel, W. (1993). The indigenous leader outreach model:
Intervention manual. Rockville, MD: US Department of
Health and Human Services, National Institute on Drug
Abuse.