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This Andean nation of 29 million people has one of the most diverse geographies in the world, with 25 regional health departments overseeing services for the sprawling capital of Lima, as well as remote villages in the high mountain ranges of La Sierra and pockets of the Amazon rainforest accessible only by boat. Poor infrastructure and social protest, involving tactics such as cutting road and rail access, can present further obstacles to planners, especially when trying to reach isolated indigenous communities. "Peru has intermediate endemicity of hepatitis B, with areas of both high and low endemicity that have left the country with high rates of liver cirrhosis and liver cancer," says Dr Manuel Pena, the Pan American Health Organization (PAHO) representative in Peru. "The annual mortality rate from liver cirrhosis is 10.45 per 100 000 population and mortality rate from liver cancer is 0.98 per 100 000 population. In endemic areas, about 7% of deaths from liver disease are related to hepatitis B infection, including liver cancer, cirrhosis and fulminant hepatitis." While the need for action was clear, rolling out such a large-scale project meant liaising between the state, private enterprise and civil society groups, says Pena. "To ensure the availability of vaccines in all health facilities in the country we used the logistic systems of the Ministry of Health as well as the Ministry of Social Security, the armed forces and some health institutions in the private sector," he says. The campaign kicked off in 2008, making Peru the first country in the world to start working towards the goal of full hepatitis B vaccine coverage for health-care workers under the Global Plan of Action on Workers' Health, which was set at the 2007 World Health Assembly. The World Health Organization (WHO) estimates that occupational exposure to hepatitis B--mainly from needlestick injuries--accounts for some 37% of the disease burden among health-care workers worldwide and that 95% of this fraction of the burden can be prevented with immunization. In the United States of America, after mandatory hepatitis B vaccination was introduced for health-care workers in 1992, annual cases dropped significantly from 17 000 in 1983 to 400 in 1995, according to research published in the Archives of Internal Medicine in 1997. Peru's health-care worker campaign began as part of a broader effort to vaccinate some 11.5 million people, the majority between the ages of 2 and 19 years. The country has been a leader in hepatitis B vaccination for the past 20 years and was one of the first to initiate hepatitis B vaccination at birth. Mariana Mendoza, director of the Ministry of Healths national immunization programme, says opposition by some health-care workers added to the logistical challenge. "For us, health-care workers are a small group of people to immunize [relative to the wider population]," she says. "In each region we have personnel who can implement this, so reaching them was not the problem ... some workers were opposed to vaccination, however." Initially, support for the hepatitis B immunization programme was high, with 95.5% of workers receiving the first dose in April 2008. But only 75% returned for a second dose. Only 53.5% of workers took the third and final dose in October the same year. [ILLUSTRATION OMITTED] Dr Yoan Mayta, head of the occupational health and safety programme for health-care workers within the Ministry of Health, was the man charged with turning around public opinion. "It's a paradox. If you can't convince a health-care worker to take the hepatitis B vaccine, whom can you convince?" Mayta concedes laughingly, when asked if he had been surprised by the level of resistance to the campaign. The opposition was spearheaded by doctors who argued that the vaccine that was being offered free to workers was substandard, containing high levels of thimerosal, a preservative that contains ethyl mercury. …

Mass vaccination of health workers in Peru