Matthew Moore: Late last week, the Centers for Disease Control and Prevention’s vaccine advisers recommended narrowing their guidance regarding hepatitis B immunization for newborns. This vaccine has been administered in newborns for more than thirty years in the US, and has been credited for lowering the amount of liver diseases caused by the virus. The recommendation for this vaccine was previously for all children. The panel now recommends that only children whose mothers test positive for hepatitis B or their status is unknown get the vaccine.
Doctor Andy Koehler is a board certified pediatrician and partner with Northwest Arkansas Pediatrics. He joined me yesterday in the Bruce Nan Applegate News Studio to talk more about the virus and the vaccine. He says that hepatitis B is transmitted by bodily fluids, and for adults, it’s most commonly through sexual contact or IV drug use. But that’s not the case for newborns.
Dr. Andy Koehler: One of the most common means for transmission in my patient population is maternal transmission to the child. And that kind of brings us to this whole discussion of why do we do hepatitis B in kids? The reason is because that transmission path is there. If we identify the kid and get them vaccinated, then we can seriously, significantly decrease that risk from happening.
The biggest problem is that in an adult, if they were to contract hepatitis B, develop acute hep B, there’s about a 5% risk that they go on to become chronic hepatitis B, which is where again, a lot of those long-term complications come. If you’re a child who contracts hepatitis B, you have a greater than 90% chance of developing chronic hep B, and so you have a greater than 90% chance of having this for the rest of your life. And again, seriously increasing your risk for cirrhosis and liver cancer. And again, there’s about a 25% chance that hepatitis B will be the cause of that child’s death in adulthood, but nevertheless.
And so again, this is one of those things that children get exposed to this. Again, we talk about maternal transmission. And that accounts for about half of all cases of pediatric hepatitis B. But the other half come from contacts with an infected person. Hepatitis B is incredibly infectious. It’s about — I mean I’ve heard anywhere from 50 to 100 times as infectious as HIV, and relatively innocuous contact can lead to that spread. So come in contact with a razor, nail clippers, a towel where even a microscopic amount of blood that got introduced into the child’s bloodstream could lead to it.
In the US, we — I think it’s important to know that hepatitis B is still prevalent in the US. We have somewhere in the neighborhood of 600,000 to a million cases. I’ve seen numbers kind of all over the place. Often our numbers are not great on it because most people are unaware that they have it. And so that is still a large population that could potentially transmit if we don’t have protected children. And those numbers are even in light of 30 years of mass vaccination.
Moore: Let’s think about, you know, you and I are having this conversation a year ago today. What sort of protocol does it look like for a kid who was born in America to get hepatitis B vaccination? What does that look like?
Dr. Koehler: So I think it’s important to remember that even before the changes that came out last week, it’s always been recommended that all children get hep B vaccine at birth. It’s never been a requirement. This was a strong recommendation. Even, you know before these changes. In the US, only about 75% of kids would get hep B vaccine at birth. And it was not uncommon for us in clinic to see a child who, for whatever reason, maybe didn’t get that vaccine at birth, and we get that first dose, you know, when they come to see us, either in that newborn period or at the two-month visit when we’re starting the primary series.
In a typical pregnancy where everything goes according to plan, hepatitis B screening is one of the main screening tests that OBs are performing on mothers to kind of assess risks. And so again, when everything goes according to plan, moms are screened during the first trimester. If we are hep B positive, there are some steps that we can take to greatly reduce your risk of contracting hepatitis B after birth. One. Immediately giving the vaccine, but also giving something called H-big or hepatitis B immunoglobulin, which basically is a direct antibody to hepatitis B that we can give along with that vaccine to make sure that viral level doesn’t take hold.
And so that was kind of our standard protocol. Screen moms. And then if positive give the hep B vaccine give H-big for everyone.
But what we know is that not everything goes according to plan. You know, sometimes there’s not a lot of prenatal care for moms. Sometimes things get wonky with testing. Sometimes people can contract hepatitis B after the first trimester. And so that is why the universal recommendation was there to go ahead to make sure we don’t miss any of those kids.
When hep B vaccine first came out in the early 80s, the initial recommendation was to do risk-based screening — started out as just, you know, if moms were positive on their screen. And then later, added risk factors based on demographics. And what they found is that it just wasn’t that effective when we just did risk-based screening. You still had about 1,000 cases a year who acquired hep B shortly after birth. And so in the early 90s, we finally came around and made that full recommendation that everyone received that dose. And now the numbers are anywhere from single digits to 20 or 30 cases a year.
Moore: When you’re having conversations with adults, with children who are trying to decide how to make the best choice. But they’re skeptical. They’re worried about the consequences of these actions on very, very tiny humans.
Dr. Koehler: Sure.
Moore: How do those conversations go from your vantage point?
Dr. Koehler: I think it’s important that we keep in mind that these are emotional times and these are stressful times and everybody’s trying to do right for their kid. And it’s just really, really hard in this day and age that we live in where we are inundated by information and not all of it’s good information.
So I think the first thing I always try to do is, again, is to be really patient and to be really understanding and knowing that usually comes from a place of fear. And so when I am having those conversations about hep B, but also, you know, all the vaccines, I think it’s important that you make sure that you know where they’re coming from.
I usually try to ask the question, is there a specific thing about this that you’re concerned about? Because if that is, then that’s where we need to start the conversation. You know, if it’s just a general oh my gosh, I’m overwhelmed. Well, then that’s a different conversation.
I think the most important thing I can tell people, especially for hep B, is just how safe this is. Again, this is a vaccine that we’ve had for decades now. It is a very well-established vaccine. Also has an incredibly low side effect profile even among vaccines. It is a low side effect profile and is just incredibly well tolerated.
But I think part of it is also helping to understand why we do it. It’s this conversation I am happy to talk about here is, is that… It drives me crazy when I hear, why are we giving, you know, kids this vaccine? You know, they’re not sexually active. They’re not doing IV drugs. No, nobody thinks that. That’s not why we’re doing this. We’re doing it because you may not be aware that, again, there are risks there. And so just trying to get to the heart of their concern. But a lot of times it is — it’s having to be patient and answer questions.
Moore: From what I have seen, they’re not necessarily concerned that it’s effective or that it’s problematic. It’s really just this overwhelming concern that we are giving children too many vaccines. And if they are not at risk of hepatitis B, then we shouldn’t be recommending it. What do you think as a professional with an expertise in this world, when you hear conversations of "we're just giving children too many vaccines now, we didn’t used to do this, and now we do.”
Dr. Koehler: So two things there. One, I think it’s important to remember that the vaccine schedule that we’re doing now is really not very new. If you go through the list of vaccines that we do on a regular basis, all of them are decades old now. And the reality is that people don’t remember how many shots they got as a kid. A lot of times that’s what I’ll kind of go through. All right. What’s the history of vaccines? Well, you know, hep B we’ve been doing since 1991. Hib, Haemophilus influenzae, we’ve been doing this since the late 80s. Pneumococcus, we’ve been doing this since 1999. ‘99 Doesn’t feel that far away from me, but it turns out it was almost, you know, 25 years ago. You know, the newest thing we’ve got on the schedule is HPV, which was in 2008. So we’re getting close to 20 years on that. A lot of these vaccines have been around for quite a while. I mean, measles, we’re going back to the 70s. Polio. We’re going back even further.
The second thing is our ability to assess the risk of vaccine-preventable illnesses is difficult in a post-vaccine world because vaccines are incredibly effective. You probably don’t know anybody who’s had a child have Hib meningitis or pneumococcus meningitis or polio. You know, I haven’t seen a case of chickenpox since I was in training because the vaccines work. And so when we start hearing about, do we really need this? I think this is the time that we need them more than ever because they’re doing such a good job.
Moore: Do you worry that this will make vulnerable families even more vulnerable?
Dr. Koehler: Yes. Yes, absolutely. The families that are most at risk are often ones that, you know, access to care is hard, that access to good information is hard. In northwest Arkansas, we have a strong medical community. Access to care is good, but not perfect. But I especially worry about our rural communities. You know, where maybe having a conversation with a pediatrician is harder to have, where that birth hep B might be the only dose they get for a while, because they may not be able to access another clinic to receive vaccines. And so yeah, I absolutely think that this, that our, our most at risk patients will suffer from this. And I do truly believe that this is going to lead to increased children in the United States developing hepatitis B, and that will have health consequences for them, you know, down the road. And that is incredibly disappointing when we’ve been doing a really good job with this.
Moore: Doctor Andy Koehler is a pediatrician with Northwest Arkansas Pediatrics. He joined me in the Bruce Nan Applegate News Studio yesterday.
Ozarks at Large transcripts are created on a rush deadline. Copy editors utilize AI tools to review work. KUAF does not publish content created by AI. Please reach out to kuafinfo@uark.edu to report an issue. The audio version is the authoritative record of KUAF programming.
