High Confidence and Demand for Hepatitis E Vaccine During an Outbreak in Bentiu, South Sudan: A Qualitative Study

Introduction In 2021 in response to an outbreak of hepatitis E in Bentiu internally displaced persons camp the South Sudanese Ministry of Health with support from Médecins Sans Frontières implemented the first-ever mass reactive vaccination campaign with HEV239 (Hecolin; Innovax, Xiamen, China). As part of an evaluation of the feasibility of hepatitis vaccination as part of an epidemic response, we conducted qualitative research to assess knowledge, attitudes, and practices related to hepatitis E and the hepatitis E vaccine. Methods We conducted 8 focus group discussions (FGDs) with community leaders, the general population of vaccine-eligible adults, vaccine-eligible pregnant women (vaccinated and non-vaccinated), and healthcare workers. FGDs were separate by gender and were audio recorded, transcribed, and translated to English by trained research assistants. Two coders used inductive thematic analysis to organize emergent themes. Results Data were collected in November 2022. Most individuals had personal experiences with hepatitis E. Hepatitis E was perceived as a dangerous disease, and almost everyone was knowledgeable about transmission pathways. Participants believed children, pregnant women, and the elderly were the highest risk groups. Participants frequently made requests for additional hepatitis E vaccination campaigns and expanded eligibility criteria for vaccination. The primary barriers to vaccination were practical issues related to being away from the camp at the time of the campaign, but participants shared that some in the community were unvaccinated due to fears about injections, social pressure, misinformation about side effects such as infertility, concerns about why some groups were eligible for vaccination and not others (e.g. young children), and a lack of information about the vaccine/vaccination campaigns. Conclusion Personal experiences with hepatitis E illness, perceived severity of illness, and confidence in organizations recommending the vaccine were drivers of high demand for hepatitis E vaccines in the first-ever use of the vaccine in an outbreak setting. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The funders of the study, MSF, were fully involved in the study design, data collection, data analysis, data interpretation and writing of the report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was granted from the MSF Ethical Review Board (ERB) and by the South Sudan Ministry of Health Research Ethics Board as part of the study protocol titled: “Effectiveness, safety and feasibility of recombinant hepatitis E vaccine HEV 239 (Hecolin) during an outbreak of hepatitis E in Bentiu, South Sudan” (MSF ERB #2167 and RERB-MOH # 54/27/09/2022). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable Excerpts of the transcripts relevant to the study are available within the paper.