New hepatitis B recommendation reveals cracks in system
Last week, an independent group of physicians and public health officials tasked with developing guidance for vaccine use scaled back its longstanding recommendation to vaccinate all newborns against hepatitis B.
The expert panel, called the Advisory Committee on Immunization Practices, or ACIP, instead recommended hepatitis B screening for all pregnant women; only infants born to mothers who test positive should then be vaccinated at birth, the panel concluded. ACIP recommended that mothers who test negative for the virus consult their physician about vaccination and weigh its risks and benefits.
Hepatitis B screening is an important tool to prevent the spread of disease; however, it is not a bulletproof solution. Screening is not universal; people other than the mother could accidentally infect a newborn; and unlike countries with national health systems, the U.S. lacks the infrastructure to guarantee that screening results are always accurate, complete or available during labor and delivery.
“Birth dose is an important safety net,” said Samuel So, a professor of surgery at Stanford University and the founder of Stanford Cancer Center’s liver cancer program.
Hepatitis B and prior vaccine guidance
Hepatitis B is a viral disease that attacks the liver and can cause both acute and chronic disease. Acute infections develop quickly and last for only a short time while chronic infections can last months or even a lifetime.
Although the majority of people with the disease have no symptoms, infection can lead to cancer, liver failure and death. About 90% of infections among infants become chronic and 25% of people infected at birth die prematurely from complications of the disease, according to the Centers for Disease Control and Prevention (CDC).
ACIP first recommended that every infant receive the vaccine in 1991. Within three decades of the newborn vaccination policy, the rate of hepatitis B among adolescents fell 99%.
Prior to 1991, about half of babies and children infected with hepatitis B were exposed by someone other than their mother, according to Michaela Jackson, the Director of Prevention Policy at the Hepatitis B Foundation.
Many physicians and medical organizations, including the American Academy of Family Physicians, criticized ACIP’s recent shift. The American Medical Association said the new guidance is “reckless and undermines decades of public confidence in a proven, lifesaving vaccine.”
ACIP’s guidance is not legally binding; however, the CDC has historically adopted the panel’s recommendations. Many states, in turn, develop their vaccination policies based on CDC guidance.
The CDC has not yet formally adopted ACIP’s change in hepatitis B guidance.
Is hepatitis B screening a reliable alternative to universal vaccination?
Screening pregnant women for hepatitis B is important, and newborn vaccination is not the only treatment option. If a pregnant patient tests positive, she can take antiviral medications such as tenofovir. One study found that daily treatment with the drug reduced the rate of mother-to-child transmission from 18% to 5%.
However, many Americans do not have access to adequate health care and screening. An analysis of health insurance and Medicaid data from 2011 to 2014 found that 12% 18% of pregnant women did not receive hepatitis B screening, as pointed out in a letter to ACIP.
In 2023, March of Dimes reported that 500,000 pregnant women in the U.S. did not receive the screening. The Department of Health and Human Services estimated that about 25,000 infants are born to mothers with hepatitis B infections, and about 1,000 of those newborns become infected with the virus.
Even when pregnant women are screened, medical records don’t always transfer between the facility where she was screened and the one where she gives birth.
“In the U.S., we don’t have a national health care system unlike some Northern European countries that can make sure every pregnant woman is tested for hepatitis B and that the result is accessible for all birth centers through a national electronic health record system,” So told Straight Arrow News.
Several ACIP members recognized these gaps in the U.S. health care system; however, they concluded that vaccinating newborns should not be the solution to these challenges.
Screening pregnant women during delivery is feasible. The test might take only a few hours if it can be conducted at the birthing facility, but could take longer if the facility has to send a blood sample to another laboratory. A growing number of women — nearly 50,000 in 2022 — opt to give birth outside of health facilities.
Moreover, even if a pregnant woman tests negative for the virus, there is a chance a newborn could contract the disease from someone else during early childhood. Hepatitis B spreads through bodily fluids, and can be transmitted through sexual contact, from mother to child at birth, and sharing needles, razors or even toothbrushes.
Outside of mother-to-child transmission, newborns may be less exposed to other sources of the virus than older children and adults. However, Teresa Lovins, a family physician in Indiana, told SAN that older children sometimes miss out on vaccination and that newborn dose is an important safety measure.
“I have seen where it gets missed. The patient may not get that one-month visit for whatever reason, and so then they’re at an increased risk of developing hepatitis down the road because they’ve missed a great opportunity,” she said.
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Ella Rae Greene, Editor In Chief
