Hep b

[Rrrrrachel]

I do think there are good reasons to vaccinate infants for hep b. I'm not a big fan of vaccinating at birth, though, when there's a pretty good idea about moms hep b status. 2 months seems soon enough. On the other hand, there is a significant number of women out there who have hep b and don't know it. What do y'all think? I guess I'm asking more as a public policy thing than what would you do for your kid thing.

[Turquesa]

Is there any research on how long the immunity from the vaccine lasts?

From a public policy standpoint, mandating it seems frivolous and over-the-top. I don't believe in compulsory vaccination, but if there must be mandates, they should be for serious diseases that pose an imminent and urgent public health crisis AND that are casually communicable in a classroom setting. Since nobody is going to cough Hep B onto another student, using it to blackmail childrens' access to public education is preposterous.

I'm glad the vaccine is available to the babies of moms who test positive for Hep B during pregnancy. But Hep B mandates are what started me on my Road to Perdition, ie questioning the vax schedule.

[womenswisdom]

From a public policy standpoint, the goal of vaccinating at birth is to have all the babies vaccinated. It would be easy enough to run a HbsAg in the hospital to confirm the mother's status if that were the true goal.

[Rrrrrachel]

Originally Posted by Turquesa 

Is there any research on how long the immunity from the vaccine lasts?
From a public policy standpoint, mandating it seems frivolous and over-the-top. I don't believe in compulsory vaccination, but if there must be mandates, they should be for serious diseases that pose an imminent and urgent public health crisis AND that are casually communicable in a classroom setting. Since nobody is going to cough Hep B onto another student, using it to blackmail childrens' access to public education is preposterous.
I'm glad the vaccine is available to the babies of moms who test positive for Hep B during pregnancy. But Hep B mandates are what started me on my Road to Perdition, ie questioning the vax schedule.

But it is communicable in the classroom. Because the viral load is so high in people who have it it's communicable through amounts of blood so small you can't see them with the eye. A kid bites another kid, two kids put the same toy in their mouths, an accident on the play ground, etc etc. like I said thousands of kids a year get hep b from a source other than their mothers. Thousands more get it from their mothers.

I do think its important to have children protected in childhood. But that goal can be accomplished with vaccination at two months.

[japonica]

Back in my former province in Canada, they don't even have it on the schedule until grade 5, so I guess it's not that much of a worry (ie. preschoolers biting each other). I'd hope that the classmates biting each other wasn't still happening as 10 and 11 year olds. Of course, the rationale the government gives for it at that age is the mutually consented biting and swapping of bodily fluids which lies just around the corner during the teen years.

I think there might be a basis for it in higher risk communities (whatever officials think those would be). But everyone? To trot out the old anecdotal chestnut, somehow I made it through my life so far without a hep B vaccination and without acquiring hep B.

I had a discussion about this with our GP actually. He thinks there's merit in hep B vaccination and played the "dirty immigrant" card, ie. "all those immigrants coming in with hep B...yada yada." I said, "Oh, immigrants like our family: who had to pass a fairly stringent medical, including hep screen, to be allowed in the country. Right." Our visas would have been denied on medical grounds if we'd failed the hep screen. So, I'm not sure there's a lot of infectious immigrants stampeding into Australia if they cannot pass the medical.

[Taximom5]

Originally Posted by japonica 

I had a discussion about this with our GP actually. He thinks there's merit in hep B vaccination and played the "dirty immigrant" card, ie. "all those immigrants coming in with hep B...yada yada." I said, "Oh, immigrants like our family: who had to pass a fairly stringent medical, including hep screen, to be allowed in the country. Right." Our visas would have been denied on medical grounds if we'd failed the hep screen. So, I'm not sure there's a lot of infectious immigrants stampeding into Australia if they cannot pass the medical.

Good point.  And in the US, immigrants not only have to be screened, they must submit to a truckload of vaccinations--including hep B--even if they provide documentation of previous immunizations. If they have proof of prior immunizations, that is supposed be taken in consideration--but my friends from Mainland China brought all their forms, which were mostly in Chinese (naturally), and the civil surgeon who examined them didn't accept any of them.  They were then given all the vaccines at once. 

This is the list on http://www.uscis.gov.  I assume that they did not receive separate measles, mumps, and rubella vaccines, since those of us who wanted those vaccines were told that they are only available as the combined MMR. 

• Hepatitis A
• Hepatitis B
• Influenza
• Influenza type b (Hib)
• Measles
• Meningococcal
• Mumps
• Pneumococcal
• Pertussis
• Polio
• Rotavirus
• Rubella
• Tetanus and diphtheria toxoids
• Varicella

You might want to ask any immigrant friends, neighbors, colleagues, etc., what their experience was.

[Dakotacakes]

I think from a public policy standpoint it is good to vaccinate infants for Hep B.  I also think Hep B is misunderstood as only transmitted sexually and through drug use, which is not the absolute truth.  HEp B is different than HIV and can live outside the body much longer, and as such, has more risk. 

I personally have been vaccinated for Hep B as has my husband.  We made the decision to vaccinate our child.  I had planned to wait until 2 months, but he got the first dose at birth.  Our reasons were we both work with higher risk categories.  I work with college students, I don't know there status, they don't always have the greatest hygiene, and they don't take the best care of themselves.  They are in my office, and occasionally so is my child.  I want the protection.  My husband works with substance abusers as a couneslor so that population is obviously high risk.

I just don't think it is as clear as :  my baby won't be having sex or using IV drug use.

[Rrrrrachel]

Just a reminder this is in the Mindful vaccination forum. I placed it here because I was interested in the opinions of people who find value in vaccination in general.

Different countries have different risks for diseases like hep b. I don't find "meh, we don't do it and we're fine" to be a compelling argument. THOUSANDS of children a year (18 thousand) were infected with hep b before they started vaccinating children. Regardless I how much fun you want to make of the idea of transmission to and between children, it happens.

As for immigrants, it's hardly as if everyone immigrates legally. The reality is there is a real risk of infection in the us for a variety of reasons. Hep b is I think the biggest viral cause of serious death and disease short of the flu.

These kinds of arguments over the basic facts are what I was trying to avoid by putting this here.

[japonica]

Originally Posted by Rrrrrachel 

Just a reminder this is in the Mindful vaccination forum. I placed it here because I was interested in the opinions of people who find value in vaccination in general.
Different countries have different risks for diseases like hep b. I don't find "meh, we don't do it and we're fine" to be a compelling argument. THOUSANDS of children a year (18 thousand) were infected with hep b before they started vaccinating children. Regardless I how much fun you want to make of the idea of transmission to and between children, it happens.
As for immigrants, it's hardly as if everyone immigrates legally. The reality is there is a real risk of infection in the us for a variety of reasons. Hep b is I think the biggest viral cause of serious death and disease short of the flu.
These kinds of arguments over the basic facts are what I was trying to avoid by putting this here.

I wasn't making fun of transmission between children. I was pointing out that in other western countries, with similar infectious disease rates and standards of health care (which I've always assumed Canada to have), transmission between young children is apparently not an issue and thus the hep B vaccine does not appear on the schedule until much later. The question was asked about public health policy. I provided one example of a country that does not routinely vaccinate infants (varying by province obviously) and yet it does not seem to be a public health issue outside of the higher risk groups.

Interesting how even if we see the merit in some vaccines, as I do, if I am critical of hep B, then I am apparently against vaccination in general. I suppose I cannot answer a question in this forum asking for opinions on health policy, if I point out that 1) many immigrants are screened for hep B and thus the "dirty immigrant card" is a misnomer for those of us who migrated legally and 2) that other countries do not vaccinate infants for hep B at infancy but later and it does not seem to impact upon their infection rates. I don't know. I thought these would be the types of issues one would want to investigate further to understand some of the variables around hep B vaccination for infants. 

[Rrrrrachel]

My response was not directed specifically at you.

What are the rates of hep b infection in children in canada?

[japonica]

I could look it up for you, but seeing as PHAC is notoriously slow at updating their online data (last reports I saw on Notifiable Diseases online was from 2006), then I doubt it will be up to date. At least the Aussies update their surveillance reports by the quarter. 

[japonica]

It's worse than I remembered. The most recent searchable data available on Notifiable Diseases is from 2004. There might be more up to date info available in the back issues of PHAC's publications (which I've checked out from time to time), but I'll post the 2004 stats for a quick look.

The rate of infection nationally in 2004 was 1.26 per 100,000 for the under 1s and 0.23 for ages 1-4. Highest rates of infection are 30-39 with 5.59 per 100,000. Interestingly, even the 60+ group has higher rates of infection than infants at 1.74. Three provinces offer the hep B vaccine in infancy. The rest have it on the schedule from grade 4 to 7.

Now, if we break it down by province, based on the old data, there doesn't seem to be much of a difference between say British Columbia, that has hep B on the schedule for infants, and Alberta, which does not. Both are listed as 0.00 per 100,000. I thought that was an error, but then the media story I linked below said that there have been no cases reported since 2005, so perhaps the 0.00 rate is not an anomaly. Still, it doesn't explain why Alberta, a provinces that does not vaccinate in infancy, also appears to have no reported cases. 

Ontario also does not vaccinate for hep B until Grade 7. Their 2004 rates of infection for infants was 1.57 per 100,000, or two reported cases, which is more of what I expected. I'd assume Alberta, back in 2004, to be around national average (1.26) or just under.

There was a media story back in 2009 about adding hep B to the schedule for infants across Canada. Three years on, it's still only offered in the three provinces. Health policy changes can occur slowly. There also has to be the usual government cost analysis and public support for it. Vaccination is not mandatory in Canada and many parents may decide that waiting until adolescence, the status quo, has been sufficient all these years, so why switch to infancy. Any changes to a nationwide infant hep B program would need the usual public awareness campaign etc.

http://www.cbc.ca/news/health/story/2009/01/19/hepatitis-b.html

Edited by japonica - 1/8/13 at 5:21pm

[Rrrrrachel]

I don't think the issue is that it's more common in infants, but that 90% of infants and 30-50% of children develop a chronic case, compared to a much smaller percentage of adults. And 25% of them eventually develop liver cancer.

[japonica]

I found some info on rates in Alberta in a provincial health document on hep B:

http://www.health.alberta.ca/documents/Guidelines-Hepatitis-B-Acute-Case-2011.pdf

From 1988 to 1996 the average rate of acute disease was 4.53 per 100,000 (range 3.09-5.54); averaging 118 cases per year (range 86-136). Universal hepatitis B immunization for grade five students was introduced in 1995. In the period 1997 to 2004, an average of 76 cases were reported annually (range 52-102), the rate decreasing to less than two cases per 100,000 population by 2004. From 2006 to 2009, there has been an average of 29 cases reported per year (range 16-36). The average rate for this time period has decreased to 0.83 with a range of 0.6-1.1 cases per 100,000 people. 

 So, according to the Alberta government stats, their rates of infection (for all ages) decreased from 4.53 per 100,000 to 0.83 per 100,000 with hep B on the schedule for older children, not infants. It will be interesting to see if the provinces who do not have hep B on the schedule for infants decide to move in that direction when, from this document anyway, it seems they want to get a handle on the infection rates in older age groups and the province dependent significant risk factors (for Alberta, this is intravenous drug use). 

[Turquesa]

Rrrrachel, where on earth are you getting your data???? :jawdrop

Prior to compulsory vaccination, the rate of transmission in children ages 0-9 was actually 360 annually.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5125a3.htm (1 in 100,000, and calculate based on the US population in that demographic of 36 million in 1990, per census figures whose link I can no longer find...) That's a far cry from all of those thousands and thousands.

Here's what I've learned from the CDC's Pink Book: http://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html

* Hep B cases peaked in the mid-1980s at 26K and markedly declined with the promotion of safer sex and other HIV prevention efforts.

* 80% of cases were in adults, 8% in adolescents, 4% in babies getting it from their mothers. The report doesn' account for the other 6%.

* 79% of cases were occurring through unsafe sex practices and contaminated needles

* 5% were resulting from other known exposures, such as drug transfusions and occupational hazards, (e.g. health care worker handling infected blood).

* 16% "deny risk factor for infection."

That doesn't automatically mean that Hep B is lurking in some scary, unknown source.  It means that self-reporting individuals with Hep B are claiming not to know.  Think about it. Until recently, being a sexually active gay man had a huge stigma attached to it.  I guess it still does with all of the one-man-one-woman crap going on...And someone sexually abusing a child or leaving dirty needles around the house probably won't disclose anything.  Self-reporting is tricky stuff.

So for all of that talk about endangering children without this vaccine, I'm not seeing a compelling reason to poke this serum under the skin of every American baby and schoolchild.

[Rrrrrachel]

I get my data from several places. Most conveniently just found here.

http://www.chop.edu/service/vaccine-education-center/a-look-at-each-vaccine/hepatitis-b-vaccine.html

I think the discrepancy may be due to the large percentage of people who don't know they have hep b because they don't immediately get symptoms? Just guessing.

[Rrrrrachel]

This is the quote from the chop website

"Before the hepatitis B vaccine, every year in the United States about 18,000 children were infected with hepatitis B virus by the time they were 10 years old. This statistic is especially important because people are much more likely to develop liver cancer or cirrhosis if they are infected early in life, rather than later in life (most people are infected with hepatitis B virus when they are adolescents and young adults)."

It's a little awkwardly worded. I'm going to look around a little more and make sure it's saying what I think it is.

[Turquesa]

And where is Offit getting his data?

[japonica]

Originally Posted by Rrrrrachel 

I don't think the issue is that it's more common in infants, but that 90% of infants and 30-50% of children develop a chronic case, compared to a much smaller percentage of adults. And 25% of them eventually develop liver cancer.

True, but looking at infection rates in places that do not have it on the schedule for infants is a starting point for how many cases we are potentially dealing with. Even if the data is also not always the most reliable. It's a place to begin.

It's too bad that PHAC is so terrible at disseminating data. I'd like to take a look at the stats for chronic vs. acute cases in the provinces that do not have it on the schedule for infants. The Alberta document says that many chronic cases report infection stemming from blood transfusion (even these days?), body piercing, and occupational contact. It'd be interesting to know how many chronic cases in Alberta, Ontario and the like, can be attributed to infections during infancy and early childhood. Mackie says one-third of chronic cases are acquired in childhood, but he's basing it on data from Vietnam, India, and Alaska, of which the first two are developing nations and the last one has indigenous communities that resemble developing nations. I'd imagine as well that no one is running titers on the Canadian kids unless there's a reason for it, so it's difficult to estimate what the rates are. You'd think though, that they'd be basing their health policy decisions on good local data, even if it's just comparing one province to another. If there's going to be a rationale for implementing hep B at birth or two months in the provinces that do not currently offer it, then there should be substantial valid Canadian data to support it. Aside from the governmental cost-benefit analysis, we also have to incorporate the estimated rates of reaction to the hep B vaccine, even if they are "rare" and the risk-benefit ratio still sways in favour of instituting the infant vaccination program.

[Rrrrrachel]

Originally Posted by Turquesa 

And where is Offit getting his data?

I wish that page was better referenced. I've seen those same stats on other pages (including the CDC) but I can't find it right now.

It's not offit, by the way. He's not the sole author of those pages, although as you obviously saw he reviews them for accuracy. Glad to have such an expert on the case, personally.