I sat nervously in the waiting room of the public health clinic looking over the vaccine schedule as my two-month-old baby snoozed in her car seat at my feet. My daughter was about to get her first round of shots and I was surprised to see hepatitis B—a disease that’s typically transmitted through sexual activity and sharing needles for drug use—on the roster. As part of the routine blood work for all pregnant women in Canada, I had been tested for the virus and had gotten the all clear. The nurse explained to me that in British Columbia, where I live, the vaccine is administered early because there is a large number of people who come from countries where hepatitis B is endemic. But across Canada, many children don’t get the hepatitis B shot until middle school.
Today, the American Academy of Pediatrics (AAP) released a statement recommending that infants receive their first dose of the three- or four-dose hepatitis B vaccine within 24 hours of birth if they’re medically stable and weigh at least four pounds, six ounces. The previous policy allowed for delaying the initial dose until the first newborn checkup, which typically takes place two weeks postpartum, but the report says that giving the vaccine right at birth offers improved protection against the disease.
It’s a small change that could save lives, according to paediatrician Elizabeth Barnett, a coauthor of the statement and member of the AAP Committee on Infectious Disease. “When a baby is infected around the time of birth or in the perinatal period, they are at much greater risk of having severe and potentially fatal complications of hepatitis B than are individuals who are infected much later in life,” she says.
The danger of hepatitis B
Hepatitis B is a virus that attacks the liver and can cause cirrhosis, liver failure and liver cancer. It’s spread through contact with infected blood and other bodily fluids, though it is not believed to be contagious through kissing. Pregnant women who are hepatitis B positive can infect their babies during delivery, but breastfeeding is safe.
Many people who are hepatitis B positive are unaware of their condition because symptoms—fever, fatigue, abdominal pain and jaundice—can take decades to appear. This is why pregnant women are routinely tested for the virus. But in the United States, about 30 percent of women don’t receive early and adequate prenatal care and screening. Vulnerable people are more likely be infected with hepatitis B and less likely to access care to find out they have it.
Even when pregnant women are tested, the results can be falsely negative, lost, misinterpreted, inaccurately reported or not communicated to the nursery, reports the AAP. The Immunization Action Coalition found 500 such errors in the US in a period of 39 months, leading to the death of at least one infant. “The birth dose of the vaccine represents a safety net for the infant who might not otherwise be protected,” Barnett says. The AAP says the vaccine is well tolerated by infants and extensive examination has found it to be safe.
On its own, the vaccine is 75 to 95 percent effective in preventing mother-child transmission when given within 24 hours of birth. Pregnant women who are screened and test positive for hepatitis B may be given antiviral therapy, and their babies are given an immunoglobulin (a protein that acts as an antibody) and the vaccine at birth. When both immunoglobulin and the vaccine are administered, the infection rate drops to about one percent.
While some people recover from hepatitis B, others are infected for life. Ninety percent of infants infected in the first year of life and 50 percent of children infected before the age of six will not recover. In the US, about 1,000 new cases are identified among the approximately four million babies born each year. The opioid crisis has led to a steep increase in the number of new hepatitis B infections in some states, which Barnett says underscores the urgency of improving perinatal prevention programs.
The hepatitis B vaccine in Canada
But if you live in certain parts of Canada, you might be wondering why the hepatitis B vaccine is often administered much later in life. The Canadian Paediatric Society recommends that all children should get the vaccine before or during early adolescence, and newborns should get it if they have mothers with hepatitis B. Because schedules are set by province and territory based on factors such as demographics, infection rates and parental acceptance of vaccines, the first of two or three doses is given at different times, including:
- Birth: New Brunswick, Northwest Territories and Nunavut
- Two months: British Columbia, Prince Edward Island, Yukon and Quebec
- Grade 5: Alberta
- Grade 6: Manitoba, Saskatchewan, and Newfoundland and Labrador
- Grade 7: Nova Scotia and Ontario
“In Canada, because we have a fairly robust screening program, it’s not clear to us that it’s really worth doing that immediate, automatic vaccine at birth,” says Mel Krajden, medical director of the BC Centre for Disease Control Public Health Lab. In fact, 97 percent of Canadian women receive prenatal care and they are required to be screened for hepatitis B during pregnancy or at the time of delivery. The result is there are 10 or fewer annual cases of the virus in babies under one year. “From my perspective, the recommendation in the States reflects certain gaps in how pregnant women are screened and supported during their pregnancy,” says Krajden.
Krajden points out that Ontario and Alberta, like BC and Quebec, have a lot of foreign-born citizens and could benefit from immunizing children earlier. “Most of our hepatitis B is occurring in immigrant populations where they’ve acquired their infection in their country of origin,” he says. “By immunizing infants, you’re really protecting kids when they’re toddlers and might be exposed to a child who’s a carrier. Toddlers in daycare settings goober all over each other.”
But there may also be a benefit to being immunized later. Krajden says there’s evidence that immunized babies lose some of the potency of the immune response over time, potentially making them susceptible to the disease when they become sexually active. He says researchers are actively studying whether or not a booster may be needed. In the meantime, if you’d like your child to receive the vaccine earlier in life, talk to your doctor.