The committee advising the Centers for Disease Control and Prevention on vaccine policy voted Friday to stop recommending that all newborns be routinely vaccinated against the hepatitis B virus – undoing a 34-year prevention strategy that has nearly eliminated early childhood hepatitis B infections in the United States.
Before the U.S. began vaccinating all infants at birth with the hepatitis B vaccine in 1991, around 18,000 children every year contracted the virus before their 10th birthday – about half of them at birth. About 90% of that subset developed a chronic infection.
In the U.S., 1 in 4 children chronically infected with hepatitis B will die prematurely from cirrhosis or liver cancer.
Today, fewer than 1,000 American children or adolescents contract the virus every year – a 95% drop. Fewer than 20 babies each year are reported infected at birth.
I am a pediatrician and preventive medicine specialist who studies vaccine delivery and policy. Vaccinating babies for hepatitis B at birth remains one of the clearest, most evidence-based ways to keep American children free of this lifelong, deadly infection.
What spurred the change?
In September, the Advisory Committee on Immunization Practices, or ACIP, an independent panel of experts that advises the CDC, debated changing the recommendation for a dose of the hepatitis B vaccine at birth, but ultimately delayed the vote.
This committee regularly reviews vaccine guidance. However, since Secretary of Health and Human Services Robert F. Kennedy Jr. disbanded the entire committee and handpicked new members, its activity has drastically departed from business as usual. The committee has long-standing procedures for evaluating evidence on the risks and benefits of vaccines, but these procedures were not followed in the September meeting and were not followed for this most recent decision.
The committee’s new recommendation keeps the hepatitis B vaccine at birth for infants whose mothers test positive for the virus. But the committee now advises that infants whose mothers test negative should consult with their health care provider. Parents and health care providers are instructed to weigh vaccine benefits, vaccine risks and infection risks using "individual-based decision-making" or "shared clinical decision-making."
The hepatitis B vaccine has an outstanding safety record and has been administered to billions of infants at birth.
On the surface, this sounds reasonable. But while parents have always been free to discuss benefits and risks with their health care providers to make a decision on what's best for their child, this change is not based on any new evidence, and it introduces uncertainty into a recommendation that has long been clear.
As a doctor, I am already seeing this uncertainty play out in the clinic. I recently had new parents ask to postpone the hepatitis B vaccine until adolescence because they believed federal health leaders had evidence that people only become infected through sexual activity or contaminated needle use.
After a brief conversation, they came to understand that this was inaccurate — children can be infected not only at birth but also through routine household or child care exposures, including shared toothbrushes or even a bite that breaks the skin. In the end, they chose to vaccinate, but this experience highlights how easily well-intentioned parents can be misled when guidance is not clear and consistent.
Why the CDC adopted universal hepatitis B shots
Hepatitis B is a virus that infects liver cells, causing inflammation and damage. It is spread through blood and bodily fluids and is easily transmitted from mother to baby during delivery.
The hepatitis B vaccine has been available since the early 1980s. Before 1991, public health guidance recommended giving newborns the hepatitis B vaccine only if they were at high risk of being infected – for example, if they were born to a mother infected with hepatitis B.
That targeted plan failed. Tens of thousands of infants were still infected each year.
Some newborns were exposed when their mothers weren't screened; others were exposed after their mothers were infected late in pregnancy, after their initial screening. And like any lab test, the screening can have false negative results, be misinterpreted or not be communicated properly to the baby's care team.
Recognizing these gaps, in 1991 the CDC recommended hepatitis B vaccination for every child starting at birth, regardless of maternal risk.
The U.S. adopted a policy of vaccinating all babies from birth because the number of people with hepatitis B infections was, and remains, relatively high, and because many mothers do not receive prenatal care, so their infections go undetected.
Meanwhile, in some European countries, like Denmark, only babies with certain risk factors receive the vaccine at birth. That’s because in those countries, hepatitis B infections are much less prevalent and pregnant mothers are more widely tested due to universal health care. Due to these differences, that approach is not effective in the United States. In fact, most World Health Organization member countries do recommend a universal birth dose.
Vaccinating at birth
The greatest danger for infants contracting hepatitis B is at birth, when contact with a mother's blood can transmit the virus. Without preventive treatment or vaccination, 70% to 90% of infants born to infected mothers will become infected themselves, and 90% of those infections will become chronic. The infection in these children silently damages their liver, potentially leading to liver cancer and death.
About 80% of parents choose to vaccinate their babies at birth. If parents choose to delay vaccination due to this new recommendation, it will leave babies unprotected during this most vulnerable window, when infection is most likely to lead to chronic infection and silently damage the liver.
A research article published Wednesday estimates that if only infants born to mothers infected with hepatitis B received the vaccine, an additional 476 perinatal hepatitis B infections would occur each year.
The hepatitis B vaccines used in the U.S. have an outstanding safety record. The only confirmed risk is an allergic reaction called anaphylaxis that occurs in roughly 1 in 600,000 doses, and no child has died from such a reaction. Extensive studies show no link to other serious conditions.
How children get exposed to hepatitis B
Infants and children continue to be vulnerable to hepatitis B long after birth.
Children can become infected through household contacts or in child care settings by exposures as ordinary as shared toothbrushes or a bite that breaks the skin. Because hepatitis B can survive for a week on household surfaces, and many carriers are unaware they are infected, even babies and toddlers of uninfected mothers remained at risk.
Full protection against hepatitis B requires a three-dose vaccine series, given at specific intervals in infancy. Anything short of the full series leaves children vulnerable for life.
In addition to changing the birth dose recommendation, the committee is now advising parents to consult with their health care provider about checking children's antibody levels after one or two doses of the vaccine to determine whether additional doses are needed. While such testing is sometimes recommended for people in high-risk groups after they get all three doses to confirm their immune system properly responded to the vaccine, it is not a substitute for completing the series.
The recommendation for all babies to receive the vaccine at birth and for infants to complete the full vaccine series is designed to protect every child, including those who slip through gaps in maternal screening or encounter the virus in everyday life. A reversion to the less effective risk-based approach threatens to erode this critical safety net.
David Higgins, Assistant Professor of Pediatrics, University of Colorado Anschutz Medical Campus
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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