Dilemma? Not really.

“But Doctor, I’m sure it’s just a mistake. See, here’s my inoculation booklet. I’ve been vaccinated, for crying out loud!”

Anna* was a 19-year-old newlywed when she decided to do her part for humanity** and donate blood for the first time. A couple of weeks later, she received a letter from Israel’s central blood bank stating her blood was HBsAg (hepatitis B surface antigen) positive, meaning she was a chronic carrier of hepatitis B and would be ineligible for future blood donation. The letter also suggested she turn to her health care provider for further testing, which is how she ended up in my office for the first time.

Anna, though she had a completely “whitebread” (meaning Ashkenazi Jewish) married surname, was born in one of the former Soviet republics. She immigrated to Israel at the age of 8, and received various catch-up immunizations at the government-run Family Health Clinic, among them a series of 3 Engerix B vaccines. She’d been a healthy child, never had an episode of jaundice or any other serious illness, never underwent surgery or any other medical procedure, and even had her ears pierced only recently (at a place where they use new needles for each client). She was also completely monogamous. Yet redoing her bloodwork only confirmed what the blood bank had told her: she was a chronic, asymptomatic carrier of hepatitis B.

A bit of medical sleuthing demonstrated that the likely source of infection was Anna’s mother, who turned out also to be a chronic carrier of hepatitis B, though she didn’t know it. Most likely, she’d infected her daughter at the time of her birth. The immunizations Anna had gotten at age 8 were like closing the stable door after the horse had long bolted. For reasons completely beyond her or anyone else’s control, she’d gotten them 8 years too late.

By now you’re probably thinking, “why is she telling me this?”. Well – first of all, cause I feel like it. My blog, my rules, yanno? 😉

But the real reason is in response to yet another misinformed blog post at Momformation from Dr. Susan Markel, the so-called “AP doctor”. She claims she finds herself facing a dilemma regarding the guidelines for hepatitis B vaccination:

A particular vaccine, for instance, Hepatitis B, is given to newborn babies who are not at risk for a disease that is spread by promiscuous sexual contact and sharing of intravenous drug needles.

I expect lay mothers, whose main source of vaccine information is Internet U., to spout such tripe. I don’t expect it from a board-certified pediatrician who’s been in practice for almost as long as I’ve been alive.

I would have expected her to have read this or something like it, which states rather clearly:

Before hepatitis B vaccination programs became routine in the United
States, an estimated 30%–40% of chronic infections are believed to have resulted from perinatal or early childhood transmission, even though <10% of reported cases of hepatitis B occurred in children aged <10 years. Chronically infected persons are at increased lifetime risk for cirrhosis and hepatocellular carcinoma (HCC) and also serve as the main reservoir for continued HBV transmission.

The WHO puts it even more starkly (emphases mine):

The routine vaccination of infants is also a high priority in countries of low endemicity because this is the only strategy that can prevent HBV infections acquired in all age groups (children, adolescents and adults). In these countries the majority of chronic infections are acquired among adolescents and adults but early childhood infections are important in maintaining the burden of chronic infection. Furthermore, many children who are infected have mothers who are NOT infected with HBV. These infections would not be prevented by identifying infants born to HBsAg-positive women and giving them a birth dose of hepatitis B vaccine that screen pregnant women for HBsAg .


Routine childhood immunization is also required in order to achieve optimal prevention of HBV infections acquired by adolescents and adults, because strategies targeting adolescent and adult risk groups have failed to control hepatitis B adequately. These immunization strategies for high-risk groups have not been very successful because of the difficulty of immunizing persons in many risk groups before they initiate high-risk behaviours and because of infections occurring among persons with no identified risk factor.

While the most common method of HBV infection in adults is as Dr. Markel states and the North America is one of the few places in the world with low endemicity for hepatitis B, the US is also a country of immigrants. A pediatrician doesn’t often know exactly where her patients’ parents were born, or where their parents came from, or the parents’ sexual histories (hepatitis B is X50-100 more infective than HIV). My point being that you can’t just assume that because Mom and Dad have Anglo-Saxon-sounding names and look like your typical hoi polloi, they must be HBV-free, or that they’ll remain so.

I don’t exepct that Dr. Markel has seen many cases of acute hepatitis B in children in her practice. Typically, a child with perinatally-acquired hepatitis B can easily fly under a pediatrician’s radar if they’re healthy and there is no obvious reason to check them for hepatitis B infection. However, they may show up in adulthood as asymptomatic carriers of the disease, or worse, after they’ve converted to the chronic active hepatitis stage – sometimes after they’ve already managed to infect others (luckily for Anna, her husband was a health worker and was already vaccinated for hepatitis B when they married). It’s still up to the pediatricians to prevent these cases from acquiring HBV on their watch, so us family practitioners, internists and hepatologists don’t have to deal with it along with the patient.

While children born to mothers of known hepatitis B carriers are supposed to be given both the hepatitis B vaccine and hepatitis B immune globulin to prevent acquiring the disease from their mothers, giving the regular vaccine alone is almost as good and can help in cases where mothers don’t know their HBV status, or the negative maternal test results are found out to have been mistaken or misinterpreted.

What about the risk of vaccinating, you ask? After all, you can’t estimate the benefit without considering the risk of vaccinating. Well, hepatitis B is one of the safest vaccines around.Quoting from the CDC link above:

The most frequently reported side effects among persons receiving hepatitis B vaccine are pain at the injection site (3%–29%) and fever >99.9° F (>37.7° C) (1%–6%). However, in placebo-controlled studies, these side effects were reported no more frequently among persons receiving hepatitis B vaccine than among persons receiving placebo . Administration of hepatitis B vaccine soon after birth has not been associated with an increased rate of elevated temperatures or microbiologic evaluations for possible sepsis in the first 21 days of life…
…A causal association has been established between receipt of hepatitis B vaccine and anaphylaxis. On the basis of data from the Vaccine Safety Datalink (VSD) project, the
estimated incidence of anaphylaxis among children and adolescents who received hepatitis B vaccine is one case per 1.1 million vaccine doses distributed (that’s extremely rare, about on par with any other vaccine and most other food allergens, for that matter).

Early postlicensure surveillance of adverse events suggested a possible association between Guillain-Barré syndrome and receipt of the first dose of plasma-derived hepatitis B vaccine
among U.S. adults. However, in a subsequent analysis of Guillain-Barré syndrome cases reported to CDC, FDA, and vaccine manufacturers, among an estimated 2.5 million adults
who received >1 dose of recombinant hepatitis B vaccine during 1986–1990, the rate of Guillain-Barré syndrome occurring after hepatitis B vaccination did not exceed the background rate among unvaccinated persons (CDC, unpublished data, 1992). A review by persons with clinical expertise concluded that evidence was insufficient to reject or accept a causal association between Guillain-Barré syndrome and hepatitis B vaccination (which, either way, would have no bearing on vaccinating babies, as Guillain-Barré is extremely rare in that age group to begin with and almost always occurs when a mother gives birth while suffering from the disease herself).

Multiple sclerosis (MS) has not been reported after hepatitis B vaccination among children. However, one retrospective case-control study reported an association between hepatitis B vaccine and MS among adults. Multiple other studies have demonstrated no association between hepatitis B vaccine and MS. Reviews of these data by panels of persons with clinical expertise have favored rejection of a causal association between hepatitis B vaccination and MS.

Chronic illnesses that have been reported in rare instances after hepatitis B vaccination include chronic fatigue syndrome, neurologic disorders (e.g., leukoencephalitis, optic neuritis, and transverse myelitis), rheumatoid arthritis, type 1 diabetes, and autoimmune disease. No evidence of a causal association between these conditions or other chronic illnesses and hepatitis B vaccine has been demonstrated...

No evidence exists of a causal association between hepatitis B vaccination, including administration of the birth dose, and sudden infant death syndrome (SIDS) or other causes of death during the first year of life. Infant death rates, including rates of SIDS, declined substantially in the United States during the 1990s, coincident with an increase in infant hepatitis B vaccination coverage from 90% and implementation of efforts to reduce SIDS through infant sleep positioning and separation from other persons in bed.

So even if we are 100% sure neither Junior or his parents are at risk for hepatits B infection (and let’s face it, we almost never are), giving the vaccine is very safe, so if Junior is vaxed, his parents don’t have to worry about getting it for him during his possibly rebellious teen/preteen years.

Why this should be a dilemma for any knowledgeable pediatrician is beyond me. While in general, a doctor should tailor his/her treatment to the patient and the guidelines be damned if adherence to them will hurt that particular patient, the overwhelming majority of infants will only benefit, or at the very least not be harmed, from administering the hepatitis B vaccine starting at birth. And in order to give good guidance to parents on this and other subjects, they need to at least attempt to understand the rationale for the guidelines and not let their personal, nature-worshipping ideology get in the way of their medical duties.

Mind you, I posted a much shorter (and politer) response in this vein to the thread at Momformation that was deleted. I’m shocked, shocked, I tell you!

Maybe you all can benefit from reading some of these stories. Or checking out the Immunization Action Coalition’s website.

——————————————————————————–

*Name and certain details have been changed for privacy. The story is 100% genuine, however.

**Israel does not pay its blood donors for their donation, though you have blood bank insurance for a year’s duration with each unit you donate. Meaning that if you or a relative needs blood during that year, you don’t have to pay for or donate a unit of blood.

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6 Responses

  1. Honestly, any blood-borne illness can be contracted by any number of means, and I think it’s a bit naive for a mother to say “Oh, they can only contract it if they become promiscuous or a drug user, and MY child won’t be one of THOSE types.” They are pretending that: a) their kid will NEVER be in an accident where they could potentially be exposed, b) their kid will NEVER get a piercing or a tattoo at a seedy parlor, something that they can’t possibly know at birth, c) their kid will never be promiscuous, which they also can’t know, d) their kid will never date or marry a promiscuous person, c) their kid will never date or marry a person who previously dated a promiscuous person etc etc.

    They are assuming that their child will grow up completely safe and unharmed and never have sex until they marry a person who similarly grew up completely safe and unharmed and similarly never had sex, and whose parents were similarly perfect. I mean, who in their right mind thinks that’s how things go these days? Hep B is such a gamble, and so easy to get compared to many other illnesses, that it’s INCREDIBLY stupid to assume that the child’s life is going to be completely free of any possible exposure.

    If I were a lawmaker, I’d vaccinate every child at birth unless the mother agreed to a blood test– if she was clear, the kid could delay the shots until like 8 or 9. But then again, I’m one of those horrible people who thinks that vaccines, as a public health measure, should be mandatory for minors even if the parents refuse them.

  2. (Unless, of course, there was a medical reason to exempt a child.)

  3. Basiorana, the point is that you can be exposed to hepatitis at birth or as a young child and not even know it. Even if your mother is hepatitis B negative.

    I’m not crazy about mandatory vaccination in general – I don’t like the idea of forcing people to do thing (mandatory for attending school is another story). But if your doctor is telling you that you really don’t need hepatitis B vaccination because babies don’t get it…your doctor is not giving you, the parent, the tools with which to make an informed decision about vaccination. And that a doctor doesn’t know this stuff, or what the rationale behind the guidelines is (no, it’s not a huge conspiracy to make Big Pharma money selling vaccines), is scandalous.

  4. Thank you so much for this post and the other two you have written that address Dr. Markel. As a new mom and Family Nurse Practitioner I have been extremely frustrated and often outraged at Dr. Markel’s posts at Babycenter’s momformation blog. I also have had multiple comments deleted when I have written in with an opposing viewpoint. Frankly I was shocked also the first time my comments in response to a post on vaccines was deleted- now I’ve come to expect it. I’m also quite disappointed with babycenter itself- that Dr. Markel who is often so slanted and biased in her writings is presented as an expert that other mother’s look to for medical and parenting advice. I used to recommend babycenter as a resource for my pregnant and new mommy patients but no longer do so because I cannot trust the information that is presented there.

    I just found your blog through a comment on sciencebasedmedicine and have spent too many hours today going through archived posts. Keep up the good work!

  5. Thanks Janna! I don’t get the appeal of Dr. Markel at Babycenter (or Dr. William Sears as an advisor to Parenting magazine, for that matter) either. Aren’t there enough good mainstream doctors who can explain the hot-button issues to parents without unnecessarily alarming and misinforming them?

  6. There are better than good enough mainstream doctors but they aren’t as well know. I can kind of get the appeal of Dr. Sears because he has the name recognition and I can’t (off the top of my head) think of any mainstream pediatricians who are quite as famous right now (although there are some up and coming ones- Dr. Laura Jana and Dr. Jennifer Shu come to mind) but I really don’t get the appeal of Dr. Markel. Maybe she was the pediatrician for the children of one of the higher ups at babycenter? Who knows.

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