Amidst the many changes surrounding the birth of a child, the family must make an important decision before leaving the hospital regarding the birth dose of hepatitis B vaccine. Many infants still aren’t receiving it, and new data shed some light on why that may be.
The birth dose of hepatitis B vaccine (HBV) is recommended by both the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices as a way of making sure that all infants of potentially infected mothers are covered.
This is important because approximately 90% of neonatal infections result in chronic hepatitis B infection. In contrast, only 10% of adult-acquired hepatitis B infections become chronic. Also, at the time of delivery in the real world, we don’t always have results for maternal hepatitis B testing from prenatal visits, and even when early prenatal results are available, results could have changed by the time of delivery.
In 2005, ACIP recommended the implementation of policies as well as procedures, laws, and regulations for birthing hospitals to ensure that all medically stable infants of HBsAg-negative mothers weighing more than 2,000 g at birth receive a birth dose of HBV before discharge from the newborn nursery (MMWR Recomm. Rep. 2005;54[RR-16]:1-23).
(Separate recommendations are given for premature infants weighing less than 2,000 g at birth. There is some confusing language in the AAP’s Red Book, and I’ll address that later in this column.)
In a retrospective cohort study of 64,425 infants born in Colorado in 2008, more than a third (38%) did not receive a birth dose of HBV (Pediatr. Infect. Dis. J. 2012;31:1-4). Of note, the proportion of infants who did not receive the birth dose increased as household income increased, with 46% of babies in households with annual incomes greater than $75,000 not receiving it, compared with just 27% of infants whose mothers reported incomes less than $15,000 per year.
The investigators also found that newborns of mothers with more education were less likely to receive the birth dose. Compared with those whose mothers had an eighth-grade education or less, those whose mothers had a bachelor’s degree, master’s degree, or doctorate/professional degree were 38%, 66%, and 51% less likely, respectively, to receive a birth dose.
Although the study could not evaluate the reasons for nonreceipt of HBV, the pattern is essentially the same as in mothers whose children have purposeful delays or who don’t receive other recommended vaccines. This surprised me a bit, although I guess it shouldn’t have. I expected to see more evenly distributed proportions across all socioeconomic groups for nonreceipt of HBV.
Hospital policy made a difference, too, the researchers found. Not surprisingly, infants born at facilities that did not offer HBV to all newborns before discharge were the least likely to receive it. Compared with infants born in hospitals that had a birth dose policy, those born in hospitals that had no policy were 39% less likely to receive it. Infants born in hospitals that had a policy to review maternal hepatitis B status but not to offer HBV to all newborns were more than twice as likely not to receive the birth dose.
To me, these data suggest two things: First, we need to be advocates for a birth dose policy in our local hospitals. Second, we need to start educating parents as early as possible about vaccines in general and the birth HBV dose in particular, ideally before the infant is born. It is important to assess the parents’ attitudes toward vaccines, and the reasons for any hesitation at any available prenatal visits, and to tailor your educational message accordingly.
Considering your approach during an initial family contact before or near birth brings up another touchy subject: whether your practice has a policy that does not permit vaccine-refusing families. What do you do if parents are insistent on vaccine refusal? If you plan to follow the prescribed method of discharging or not accepting such a family, consider also offering them a list of trustworthy colleagues in the community who are willing to accommodate the family’s approach. Leaving children unvaccinated is far from optimal, but I believe that providing information on trustworthy alternative practices is in the child’s best interest. Otherwise, parents may end up choosing a practice in which overall care is substandard.
Finally, I recently was made aware of potentially confusing wording in the ACIP and 2009 Red Book recommendations regarding infants born weighing less than 2,000 grams. The wording states that preterm infants of HBsAg-negative mothers with a birth weight less than 2,000 g can receive HBV starting at 1 month of chronological age, or at hospital discharge prior to 1 month of chronological age. This implies that a dose given when the weight is less than 2,000 g could count as one of the three required doses, if it is given at hospital discharge. However, in reality, that dose cannot be considered the first in the series if the infant still weighs less than 2,000 g at that time. The child will still need three more doses after its weight surpasses 2,000 g. This potentially confusing wording is likely to change in the upcoming 2012 Red Book edition.