A vaccine advisory committee to the Centers for Disease Control and Prevention was preparing to vote Friday on whether to abandon the recommended birth dose of the hepatitis B vaccine, a move that would be the body’s most controversial decision since it was reviewed by Health and Human Services Secretary Robert F. Kennedy Jr. in June.
The hepatitis B vaccine has long been a favorite target of vaccine opponents. But changing this decades-old recommendation has proven tricky, even for Kennedy’s hand-picked Advisory Committee on Immunization Practices.
A vote planned for September was postponed after violent disagreements among members, whose bickering on Thursday repeatedly turned into shouting.
“We’re trying to assess a moving target,” Dr. Joseph R. Hibbeln, one of the initiative’s strongest opponents, said at the meeting.
Although a change in the current recommendation would not prevent newborns from receiving the vaccine, Medicaid and other public insurance programs would no longer be required to cover it, putting the birth dose out of reach for millions of poor families and complicating access for many others.
Unlike most vaccine-preventable diseases, such as whooping cough and chickenpox, hepatitis B is usually asymptomatic and often spreads silently until midlife, when one in four infected people develop liver cancer or cirrhosis.
“It’s one of the cancers with the highest mortality in the United States,” said Dr. Su Wang, medical director of the viral hepatitis programs and the Asian Health Center at Cooperman Barnabas Medical Center in New Jersey, who lives with the disease. “The life expectancy we give people is six months on average. »
Opponents of current vaccine guidelines — among them Kennedy, surgeon general nominee Casey Means and President Trump — characterize the virus as the result of high-risk “adult” behavior, including sex and intravenous drug use.
“Hepatitis B is transmitted sexually,” Trump said at a White House press conference in September. “There is no reason to give a newborn baby hepatitis B.”
But experts say that’s not how most people get the disease.
“It’s primarily passed from mother to child,” said Dr. Chari Cohen, president of the Hepatitis B Foundation.
The majority of infected mothers are immigrants – particularly from the Philippines, China and Vietnam – making birth vaccination an urgent priority for many California families.
For some administration officials and panel members, the prevalence of the disease in immigrant communities is a topic of discussion.
“The elephant in the room is immigration — we’ve had years of illegal immigration, undocumented people coming from countries with high endemicity,” said Dr. Evelyn Griffin, one of the panel’s strongest advocates for change.
“We have problems that adults need to solve with our resources there, rather than having babies solve that problem for us,” she said.
Griffin and other opponents of the current vaccine schedule say vaccinating everyone places an unfair burden on healthy newborns from nonimmigrant families whose mothers have tested negative or have few risk factors for disease.
But experts say the proposed alternative — universal prenatal testing and aggressive risk assessment — is unrealistic in the current U.S. health care system. Today, fewer than 85 percent of mothers are screened — a number that experts say will decline sharply if health care subsidies disappear and Medicaid enrollment is cut in the coming months.
“Our previous risk-based vaccination strategy failed,” said Katrin Werner Perez of the Alliance for Aging Research. “Before the move to universal vaccination in 1991, nearly 20,000 babies and children were infected each year in the United States. »
For babies exposed to the blood-borne virus in utero or during delivery, every minute of delay in giving the injection increases the risk of transmission. This reality prompted U.S. public health officials to extend the first dose from infancy, when it was administered in the 1980s, to the first 24 hours of life, a recommendation the CDC has maintained since 1991.
“[The vaccine] has saved thousands, if not millions, of lives in the United States alone,” Cohen said. “There is more safety and effectiveness data on the hepatitis B vaccine than on anything else we put in our bodies.”
According to the data, those who contract hepatitis as infants are much more likely than those who contract it as adults to develop chronic and ultimately fatal infections.
Since the virus can live on surfaces for up to a week, doctors and public health experts emphasize that babies can contract it even from seemingly insignificant exposures. Caregivers might not know they have the disease and are unlikely to be tested, making giving the birth dose more urgent, they said.
“Mom is not the only person around the baby,” said Wang, who told the panel Thursday that she likely contracted the disease from her grandparents. “There’s grandparents, caregivers, other young children. You’re basically leaving that baby vulnerable.”
Even a small cut from shared nail clippers risks infection, data shows.
Kennedy and his allies on the panel counter that the vaccine is unnecessary for most infants and that delaying it would offer parents the opportunity to participate in “shared clinical decision-making” about whether and when to vaccinate.
Yet the panel has so far struggled to come together around an alternative recommendation. A vote scheduled for Thursday was postponed in part because the proposed text remained in flux even as the meeting was underway.
“This is the third version of the questions that most ACIP members have received in 72 hours,” Hibbeln said.
Hibbeln and his colleague, Dr. Cody Meissner, were strong opponents of a change in the birth dose recommendation when it was first debated in September.
“We will create new doubts in the public’s mind that are not justified,” Meissner said.
Others said the measure would not go far enough.
“I don’t even see where the argument is for vaccinating younger children who live in a normal environment,” panelist Dr. Retsef Levi said in September.
In addition to limiting public coverage of the vaccine, a change in the recommendation could also force privately insured parents to navigate multiple layers of complex authorizations in order to access a birth dose, experts warned.
Many feared the move would further stigmatize the vaccine at a time when many parents are refusing it simply because the recommendation is under review.
“States and hospitals are reporting a decline in hepatitis B vaccination,” said Kayla Inthabandith of the Center for Advancing Health Equity in Rural and Underserved Communities. “Even some mothers living with hepatitis B refuse the birth dose, putting their own infants at the highest risk of infection. »
Moving the recommendation from the first day of life to the second month could lead to 1,400 new infections a year, experts warn.
“Any child who gets a hepatitis B infection because we change policy is one child too many,” said Dr. Judith Shlay. “I want us to ensure that no child becomes infected with hepatitis B.”
