Protecting the Innocent

Physicians Urged to Make Sure Infants Get Hepatitis B Protection  

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Legislative Affairs Feature -- September 2003

By  Ken Ortolon
Senior Editor

It's a killer virus 100 times more infectious than HIV, it produces more than 100,000 cases annually in the United States, and it infected at least 1,110 Texans last year. And even though children are among those most vulnerable to hepatitis B, health officials say many Texas children aren't being vaccinated because some parents and physicians are confused about how it is transmitted and when the first dose of the vaccine should be administered.

Adding to health officials' concern is a new state law making it easier for parents to keep their children from being immunized. They fear it will lead to an increase in hepatitis B and other vaccine-preventable diseases among Texas youngsters.

As a result, Texas Department of Health (TDH) officials are urging physicians and hospitals to make sure all Texas newborns get the hepatitis B vaccine at birth.

The Thimerosal Controversy

Since 1992, the American Academy of Pediatrics (AAP) has recommended that all infants receive the hepatitis B vaccine at birth and two additional doses by age 12 months to prevent perinatal transmission of the disease from mothers who test positive for the hepatitis B surface antigen (HBsAg). 

For Web sites dealing with hepatitis B, see MedBytes.

"Coming through the birth canal is one of the easiest ways babies get hepatitis B," said Dallas pediatrician Molly Ann Droge, MD, chair of Texas Medical Association's Committee on Child and adolescent Health. "Babies are at very high risk of this."

The risk is so high that in 1999 the Texas Legislature required all pregnant women to be screened for HBsAg infection during gestation and at delivery. The U.S. Centers for Disease Control and Prevention (CDC) estimates that between 850 and 1,265 infants are born in Texas each year to HBsAg-positive mothers. The American College of Obstetricians and Gynecologists, CDC's Division of Viral Hepatitis, and AAP recommend these infants receive the hepatitis B vaccine and a dose of hepatitis B immune globulin (HBIG) within 12 hours of birth to prevent perinatal transmission.

Even so, there's no guarantee newborns won't get the disease. Seven of the 573 Texas infants born in 1998 and 1999 who received both the vaccine and HBIG at birth and who received two additional vaccine doses by age 12 months later tested positive for hepatitis B.

While infants born to hepatitis B-positive mothers are most at risk, public health officials say all infants should be immunized for several reasons. First, despite the screening requirement, not all women are being screened. Second, a certain number of screenings will indicate the mother is infection-free even thought she isn't. Finally, children and adults can be exposed to hepatitis B through contact with blood or any other body fluids from an infected person.

But, in 1999, AAP changed its recommendations for immediate immunization of newborns amid controversy over the presence of thimerosal, which contains mercury, in childhood vaccines. The change resulted from a U.S. Food and Drug Administration review that showed thimerosal exposure from all routine vaccinations in the first six months of life could exceed some government-recommended limits. Some parents also worried that thimerosal was linked to developmental disorders in some children. The new AAP recommendation was to give the first dose of hepatitis B vaccine at two to six months for all children born to mothers who tested negative for hepatitis.

Sharilyn Stanley, MD, associate commissioner for disease control and prevention at TDH, says fears of infants being exposed to mercury were legitimate, so policy was "briefly changed to say hold off on the birth dose of hepatitis B."

But that concern no longer exists, she says. Even though there is no scientific evidence linking thirmerosal and neurodevelopmental disorders, vaccine makers removed the compound from the hepatitis B and other vaccines, and AAP rescinded its recommendation to delay the birth dose. In addition, the federal Advisory Committee on Immunization Practices voted in 2001 to amend its vaccine recommendations to agree with AAP policy.

"The fact is that thimerosal is gone, it's out of the vaccines," Dr. Stanley said. "So that changes the dynamic. We are back to saying we want universal vaccination for hepatitis B, and that means that the birth dose should be given. Unfortunately, a lot of hospitals and physicians have not changed their policies to encourage giving that dose."

The Sex Equation

Health care professionals have been slow to comply with the new recommendations and some parents have objected to the hepatitis B vaccine, largely due to the misperception that hepatitis B is strictly a sexually transmitted disease.

"That's a common misperception not only among parents but also among physicians," Dr. Stanley said.

In a June 2002 report, TDH documented cases of hepatitis B being transmitted from child to child and from child to adult in child care centers and schools. It also cited cases of transmission between athletes in sporting events, such as wrestling matches.

The TDH report cited a 2001 article by Armstrong et. al. published in the journal Pediatrics , which concluded that person-to-person transmission is responsible for thousands of new cases of infection annually. "The normal play of young children can involve aggressive behavior such as biting or scratching," the TDH report stated. "Young children frequently engage in 'rough' play that may result in open, bleeding wounds. Young children are also notorious for unhygienic contact with each other. Combine all these elements and one can see why instances of childhood infections have occurred in childcare, schools, and play settings."

What's more, the virus is highly infectious and can live and remain infectious on toys, balls, and other unsterilized surfaces for as long as 30 days, the report said.

Still, resistance to using the vaccine persists and some physicians fear it could get even worse, thanks to a new Texas law that makes it easier for parents to object to vaccinations for their children.

A provision inserted late in the 2003 legislative session into a bill reorganizing state health and human services agencies allows students who have not had all required vaccines to attend public schools. Those students' parents have to file a conscientious objection to any vaccine they don't want their children to have.

Gayle Harris, director of TMA's Public Health Department, says supporters of the law are driven mostly by a desire to keep their children from getting the measles, mumps, and rubella vaccine and the hepatitis B vaccine. Because they think hepatitis B is a sexually transmitted disease, she said, "they don't feel like their infants should be vaccinated against a disease they're not going to get."

While it is still unclear how many parents might choose to opt out of the hepatitis B vaccine, Drs. Stanley and Droge say the new law could devastate the attempts to control the disease.

"That's an absolute fear," Dr. Stanley said. "That's why it's imperative that physicians are fully informed and educated about the true risks of hepatitis B."

Dr. Droge says it is unfortunate that many parents who object to vaccines are operating on "unfounded or exaggerated" concerns. Allowing unvaccinated children into the schools only compounds the fact that Texas ranks near the bottom nationally in making sure young children receive all recommended vaccinations.

"The group that pushed through the conscientious objection has a lot of concerns about immunizations," she said. "Unfortunately, those are not always factually based or based on medical evidence. And, if we have kids in schools without these vaccines, the diseases will be back. The germs still exist in nature. We will have another epidemic; it's only a matter of time."

Assessing the Problem

TDH says it doesn't really know how Texas physicians and hospitals are doing at this point in administering the birth dose of hepatitis B vaccine, but it does know some children are falling through the cracks because perinatal transmission of the disease continues. At least three cases of perinatal transmission were reported in Texas last year. And, according to 2001 National Immunization Survey data, only 86.9 percent of Texas children aged 19 to 35 months had received the recommended three doses of hepatitis B vaccine.

TDH is assessing how widespread the vaccine problem is. Earlier this year, it contracted with the Texas Medical Foundation to survey 65 Texas hospitals with the highest number of deliveries to determine how well they are screening pregnant women for hepatitis B infection and administering the hepatitis B vaccine. Those data are being analyzed now and should be released later this year.

David Bastis, program manager for surveillance and epidemiology in the TDH Immunization Division, says the hospitals enthusiastically participated in the survey. "The survey will give them back information to improve their processes, and that's what we intended."

Meanwhile, Dr. Droge says physicians must take the lead in educating parents that vaccines are safe, effective, and necessary to protect all Texans from deadly diseases.

"The concern about the conscientious objection provision is that families will now be able to fill out an affidavit, get it notarized, and send it to the schools without really having an opportunity to discuss the issue with a medical professional," she said. "It's important that parents don't depend on just what they might find on the Internet or hear from their neighbors. It's important that they have an opportunity to discuss these life-or-death issues with their physicians and understand how important immunizations are to the health of our children."

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

Cases of Acute Hepatitis B Viral Infection in Texas, by Age, 1998 Through 2002

 

Age (years)

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

<1

9

8

15

4

2

2

8

2

19

2

1

0

0

1-4

17

15

15

9

13

5

2

11

12

6

1

1

0

5-9

11

13

11

15

6

11

3

16

18

2

2

3

3

10-14

18

21

17

27

17

8

14

12

28

10

11

0

2

15-19

128

109

111

105

89

71

53

72

116

61

67

45

30

20-29

632

622

508

410

424

293

344

272

406

219

285

176

225

30-39

493

558

420

369

430

366

369

375

617

239

306

189

305

40-49

182

237

193

176

210

210

226

260

424

185

211

158

291

50-59

64

88

67

84

80

81

111

112

152

67

83

75

124

60+

98

114

91

86

105

84

96

95

137

47

77

56

94

Unknown

137

173

81

70

46

44

32

18

31

26

15

11

36

Total

1,789

1,958

1,528

1,354

1,422

1,211

1,258

1,245

1,960

864

1,059

714

1,110

Source: Texas Department of Health

immuntable

September 2003 Texas Medicine Contents
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