Hepatitis B Recommendation From the CDC Likely to Change

Hepatitis B isn’t a fun illness. In it’s acute form, it generally has flu like symptoms and occasionally jaundice. This acute form is rarely life-threatening. However, about 5-10% of adults with acute hep B will develop chronic hepatitis B, which can cause life long complications including liver cancer. Hepatis B can be spread from mother to newborn - and when this happens, there is approximately a 90% chance of developing chronic hepatitis B. Worldwide, approximately 1-2 billion people have hep B (worst concentations in southeast Asia). In America, it’s estimated to be about 2.4 million of <1% of the population, but was much higher back in the early 80s when IV drugs and the sexual revolution without knowledge of sexually transmitted/bloodborne illnesses such as the emerging HIV epidemic was practically nonexistent. Changes in behavior along with better testing and vaccination have now significantly lowered those rates. Back then, approximately 20,000 babies developed Hep B each year, while today, that number is approximately 1000.

Due to the rising Hep B crisis, there was a strong desire for a hep B vaccine that could prevent transmission. The good news is, we were really successful at making one. The hepatitis B vaccine is well tolerated, highly effective and has probably helped avoid many liver cancers. I’m old and was born before 1991, so I got my Hep B shot in high school. I only remember getting it done because it was the day before my NJROTC unit went to an Atlanta Braves Game to present the colors and I could barely hold up the flag. I also got the meningococcal vacine the same day, so who knows which was to blame? However, starting in 1991 when the vaccine was developed, we began vaccinating all newborns. One of the special things about the Hepatiis B vaccine is that if a baby is born to a mom with Hepatitis B and is given the vaccine within 4 hours of birth along with a dose of Hep B immune globulin, then the chance of that baby developing chronic Hepatitis B is significantly reduced to < 1%. It’s a great triumph of modern medicine. Given the public health challenges we were facing and the widespread lack of knowledge, contamination of the blood supplies, etc, I think they made the right call.

The question before the CDC today is, do we need to continue doing things the same way 30+ years later in a changing health landscape. The vaccine advisory committee says no and the CDC director is expected to agree with the new recommendations.

I don’t know what the testing protocol and turn around times were like in 1991. I was in 1st grade after all. What I do know is how good are system is now. Every woman is screened for Hep B when she has her first prenatal labs - generally in the first trimester. She is also screened again on admittance to Labor and Delivery. Office screening is usually back within 24 hours and hospital screening within 1-3 hours. So, we are really good at identifying who has hepatitis B and also, which fetuses and newborns are at risk of transmission. If a mom has hepatitis B, her newborn should absolutely be given the vaccination early along with whatever other preventative treatments are recommended by the pediatrician.

What do we do about all the mom’s that don’t have Hep B? Approximately <1% of the US population has Hep B. In my somewhat narrow sample size of the 10s of thousands of women whose prenatal care I’ve been involved in, I’ve met exactly one person with chronic Hep B who was born in this country - and she was older than me at the time. Every other case I’ve seen has been in someone born in Southeast Asia. (Please don’t misconstrue this as predjudice - its a fact that it is endemic there (maybe 25-30% of people) and has to do with alot of factors - lack of testing, lack of vaccination, lack of access to care generally.) Do all the women with multiple negative Hep B tests need to have their baby vaccinated in the delivery room? Given that even if a woman has no prenatal care, we can get a result on a hep B test extremely quickly, do we still need to continue with mass unquestioned vaccination? I have long felt the answer was no and personally chose to delay my kids’s Hep B vaccines - they are now 4 and 9 and both have received their series now and are up to date on their vaccines. - and now the CDC seems to agree. Do I think we should stop all vaccination for Hep B (or anything else)? Of course not. I think it’s a good vaccine, it’s well tolerated and work in many industries requires it.

The debate at the CDC centered on this - we have been successful and there are no known harms to the vaccine, so we should do things the same way we have always done and if we make any change to the recommendation, people might doubt the vaccine’s safety vs. We have been so successful and our testing is so much better and we do great with universal screening, so we should allow parents to make their own decision about when and whether to vaccinate their child. I think the vaccine is very safe, but I also think the immune system is more receptive as the child ages and that by waiting until after 1 year of age, the child is less likely to have a negative reaction and the vaccine will work better in the long term. (Of note, I have no scientific evidence to back that up, just a basic knowledge of the immune system.) I don’t believe the people who favor continued universal vaccination do so to make more money or some conspiratorial reason. Their argument - and it is a good one - is to make it as easy as possible for parents. I like easy. I also believe that if we continue to try to use vaccines like a cudgel to tell parents their opinions about their child’s care don’t matter, we will ceate further mistrust. The desire to change how many vaccines kid’s get at such a young age isn’t coming from some practically unseen corner of the internet, its a question I’m asked regularly - by highly educated parents. I’m far more concerned that if we don’t allow Hep B negative mom’s to move this vaccine (for a disease their newborn isn’t at risk of) that we are going to create more parents who won’t give the MMR vaccine or any of the far more important ones for young kids. I would call that vaccine one of the most important of childhood. I think if we discuss this topic in a way that is based on fear mongering and politics, we will not reach a solution that all parties can agree on - or at least live with. What we need are people who are willing to put parent’s first and, if nothing else, generate some data with a large randominzed trial of using the different schedules, or perhaps an in depth comparison of other countries that do things differently. We could compare Italy, Sweden, Denmark (only vaccinate high risk individuals at birth) and Poland, Portgal and Romania (universal vaccination). What this shows to me is that well meaning, educated people can look at the evidence and draw slightly different conculsions.

I hope that parents will be given more of a say. I hope that the press can discuss this in reasonable terms. I hope that no baby ever gets Hep B and I think we can best accomplish this if we partner with parents and give them a voice to choose when and how to vaccinate their children.