Hepatitis B Vaccine: First Dose Within 24 Hours of Birth
CDC (Center for Disease Control), ACIP (Advisory Committee on Immunization Practices), and AAP (American Academy of Pediatrics) have all updated their recommendation of the timing of the first dose of hepatitis B vaccine in a newborn. They are now recommending that the first dose of Hepatitis B vaccine be given to any newborn weighing more than 2000 grams (4 lb 7 oz.) at birth and born to a non-Hepatitis B infected mother, be given within the first 24 hours. If the mother is hepatitis B positive or her hepatitis B status is unknown, then the first dose should be given within the first 12 hours of birth. The previous recommendations (Issued in 2005) by these organizations were more permissive. They allowed practitioners the option to delay this dose. In October of 2016, the ACIP rescinded the permissive language.
It’s about time!
Clinicians depend on these organizations to analyze the available data and make sensible recommendations. These organizations are great, but not perfect. The recommendations are usually committee statements. I imagine there is a lot of compromising going on with the wording of the text. They are essentially writing the “Bible” we follow. In my opinion, they occasionally fail to realize the consequences of how their statements are worded and the effect they will have on day to day practice and their implementation in the real world.
The 2005 Guidelines
The permissiveness of the 2005 guidelines never made sense to me. Let me explain the problem with them and why they were updated.
Hepatitis B has some similarities to HIV. One can be infected with the virus for a long time and not have any recognizable symptoms. Both can be transmitted through blood or sexual contact. Although pregnant women are screened during prenatal care for their hepatitis B status, this is not foolproof. Not all women get complete (or any) prenatal care. Laboratory errors can occur. Charting errors can occur. Theoretically, a woman could test negative for hepatitis B during her pregnancy and become infected with it after the testing and before giving birth (with no symptoms to indicate it happened).
If a newborn is born to a Hepatitis B positive mother and the newborn isn’t given the vaccine at birth there is at least a 50% chance the child will become infected. Infected at birth there is a high probability of the disease becoming chronic and it even could eventually kill the child. If the Hepatitis B vaccine series is started at say 2 to 6 weeks of age it won’t protect at all against that birth exposure. But, if the first vaccine dose is given to the exposed newborn within 24 hours of birth, then 85% of those infections will be prevented just by the timing of the first dose of the vaccine.
So, since hepatitis B vaccine is a routine childhood vaccine and you are planning to vaccinate the newborn anyway, why the hell would you want to miss the opportunity to protect against an inadvertent newborn exposure?
So my routine spiel when making rounds in the newborn nursery included this explanation as to why the baby should get the first dose of vaccine in the hospital and not wait until the first or second checkup for it. I had to fight constantly with conflicting information given to the mothers by nurses or other doctors who were providing the then “acceptable advice” that is was ok to wait. “That there was no reason the baby had to get it while in the hospital”. As a result of the conflicting advice out there, although I could persuade most of the mothers to start the vaccine in the hospital, I could not succeed in all cases. Now, except for some “diehards” that are slow to accept the updated recommendations, that shouldn’t be a problem.
Arnold Solof, MD
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