The prevalence of hepatitis B in the United States has remained steady at about 5% of the general population over the past two decades[1]. The hepatitis B virus (HBV) is transmitted through contact with blood or other body fluids of an infected person, or through household contacts. Carriers are able to give it to others even though they do not appear to be sick. At least 200,000 new infections occur yearly, with 5-10% of infected persons developing chronic infection with subsequent high risk of cirrhosis, liver cancer, and death [2]. The 6,000-8,000 newborns each year that acquire HBV from their mother face a much higher risk of chronic infection (90%) and death (23%) than do adults [3,4]. Only universal immunization can reduce the number of new infections [5]. Laws requiring vaccination for school and day-care entry form a crucial part of the public health safety net and provide the capability not only to control diseases but also to eradicate them.
The hepatitis B vaccine's effectiveness and safety have been rigorously documented: 95% of children and 90% of adults receiving the full 3-dose series develop protective antibodies [6]. Among the 20 million Americans who have received hepatitis B vaccine so far, the most commonly reported side effects are pain at the injection site and mild-to-moderate fever. Anaphylaxis has been reported, with an estimated incidence of 1 per 600,000 doses and no fatalities [7-9]. Immunologic protection against chronic hepatitis B infection persists for at least 12 years after vaccination and may persist even after the antibody is no longer detectable [10-13]. So far, no data support a need for "booster" doses, but research on this point is still being done.
Despite these facts, opponents of immunization have raised public concerns about the safety and necessity of hepatitis B immunization. In January 1999, an ABC news segment featured persons who claim to have suffered chronic diseases as a consequence of receiving Hepatitis B vaccine. More recently, the National Vaccine Information Center's newsletter ("The Vaccine Reaction') charged that:
Concerns regarding a link between hepatitis B vaccination and multiple sclerosis first arose due to anecdotal reports from France. Mandatory vaccination of adolescents there was then suspended because of political pressure, not scientific evidence. Universal vaccination of infants in France has subsequently been reinstated [18]. The precise cause of MS, a presumed autoimmune disease, is unknown. The Medical Advisory Board of the National Multiple Sclerosis Society has concluded that there is no evidence of a link between hepatitis B vaccination and MS [19]. Worldwide use of over a billion doses of hepatitis B vaccine has not resulted in increased incidence of MS and other demyelinating diseases, as would be expected if there were a causal connection [20]. Other evidence against a hepatitis B vaccine-MS connection includes:
Information obtained from the Vaccine Adverse Events Reporting System (VAERS) has been cited as "evidence" for serious adverse and chronic health conditions caused by hepatitis B vaccine. VAERS is a surveillance system for adverse health effects occurring after immunization; reports should not be construed as evidence of "vaccine reactions." [22] Vaccinations are frequent in adults and children, and most medical conditions occurring afterward represent coincidental association. Many of the case reports by anti-vaccine lobbyists suffer from faulty medical logic, as exemplified by the case of a 13-day-old said to have died from sudden infant death syndrome (SIDS) brought on by hepatitis B vaccination. SIDS -- by definition -- has no known cause and is not diagnosable in a child under one month of age.
Contrary to strident assertions from the anti-vaccination groups, mandatory state immunization laws do not exist to force compliance with vaccination but rather to safeguard the health of children and their communities. Medical exemptions from vaccination exist in all states, and religious exemptions are available in some states. Many states do not permit philosophical or "selective religious" exemption from single vaccines such as hepatitis B. Nationally only about 1% of children are unvaccinated for religious or philosophical reasons. These children are at increased risk of vaccine-preventable diseases (for example up to 60-fold risk of measles) and would require protective isolation if such diseases were detected in their communities, schools, or day-care centers.
Religious groups that reject immunization have experienced outbreaks of polio, measles, whooping cough, and congenital rubella syndrome. Weakening of school and day-care vaccination requirements would result in lower coverage levels, higher disease incidence, and more deaths, as illustrated by the 1988-91 U.S. measles outbreak. States that enforce mandatory immunization laws have documented decreases in measles and other vaccine-preventable diseases. In a recent Dutch epidemic, nearly 3,000 cases of measures were reported, with three deaths and 68 cases of hospitalization [24].
Universal infant and adolescent immunization against hepatitis B remains the cornerstone of prevention of this prevalent cause of morbidity and mortality. Although routine hepatitis B vaccination of newborns and adolescents has begun too recently to detect a significant reduction in the incidence of disease, the benefit will eventually become obvious.
This article was written by John Iskander, MD, MPH, a pediatrician who works for the Department of Health in Columbia, South Carolina.