Misconceptions about Immunization

Misconception #10:
Hepatitis B vaccine causes chronic health
problems including multiple sclerosis

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 [6-8]. 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 [9-12]. So far, no data support a need for "booster" doses, but research on this point is still being done.

Unwarranted Criticism

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') falsely 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 [17]. 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 [18]. 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." [21] 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 measles were reported, with three deaths and 68 cases of hospitalization [22].

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.

For Additional Information

References

  1. McQuillan GM and others. Prevalence of hepatitis B virus infection in the United States. American Journal of Public Health 89:14-18, 1999.
  2. Centers for Disease Control and Prevention. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. Mortality and Morbidity Weekly Report 40 (RR-13):1-19. 1991.
  3. Beasley RP, Hwang L-Y. Postnatal infectivity of hepatitis B surface antigen-carrier mothers. Journal of Infectious Disease 147:185-190, 1983.
  4. McMahon and others. Acute hepatitis B virus infection: Relation of age to the clinical expression of disease and subsequent development of the carrier state. Journal of Infectious Disease 151: 99-603, 1985.
  5. Update Recommendations to prevent hepatitis B virus transmission - United States. Morbidity and Mortality Weekly Report 44:574-575, 1995.
  6. American Academy of Pediatrics. Hepatitis B. In: Peter G, editor. 1997 Red Book: Report of the Committee on Infectious Diseases, 24th edition, p 251.
  7. Niu MT and others. Comparative safety data of two recombinant hepatitis B vaccines in children: data from the Vaccine Adverse Event Reporting System (VAERS) and Vaccine Safety Datalink (VSD). Journal of Clinical Epidemiology 51:503-510, 1998.
  8. Greenberg DP. Pediatric experience with recombinant hepatitis B vaccines and relevant safety and immunization studies. Pediatric Infectious Disease Journal 12:438-445, 1993.
  9. Hadler SC and others. Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. New England Journal of Medicine 315:209-214, 1986.
  10. Wainwright RB and others. Duration of immunogenicity and efficacy of hepatitis B vaccine in a Yupik Eskimo population. JAMA 261:2362-2366, 1989.
  11. Lo K-J and others. Long-term immunogenicity and efficacy of hepatitis B vaccine in infants born to HBeAg-positive HBsAg-carrier mothers. Hepatology 8:1647-1650, 1988.
  12. Hwang L-Y, Lee C-Y, Beasley RP. Five year follow-up of HBV vaccination with plasma-derived vaccine in neonates. Evaluation of immunogenicity and efficacy against perinatal transmission. In Hollinger FB, Lemon SM, Margolis HS, editors. Viral Hepatitis and Liver Disease. Baltimore: Williams & Wilkins, 1991, pp 759-761.
  13. CDC. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. Mortality and Morbidity Weekly Report 38(Suppl 6):5-15, 1989.
  14. Alter MJ and others. The changing epidemiology of hepatitis B in the United States. Need for alternative vaccination strategies. JAMA 263:1218-22, 1990.
  15. Margolis HS, Alter MJ, Hadler SC. Hepatitis B: Evolving epidemiology and implications for control. Seminars in Liver Disease 11:84-92, 1991.
  16. West DJ, Margolis HS. Prevention of hepatitis B virus infection in the United States: A pediatric perspective. Pediatric Infectious Disease Journal 11:866-874, 1992.
  17. World Health Organization. Expanded programme on immunization. Lack of evidence that hepatitis B vaccine causes multiple sclerosis. Weekly Epidemiological Record 72:149-152, 1997.
  18. National Multiple Sclerosis Society. Hepatitis B vaccine and multiple sclerosis. Press Release, Aug 21, 1998, reissued Jan 22, 1999.
  19. Shaw FE and others. Postmarketing surveillance for neurologic adverse events reported after hepatitis B vaccination. American Journal of Epidemiology 127:337-352, 1988.
  20. Emini EA and others. Production and immunologic analysis of recombinant hepatitis B vaccine. Journal of Infection 13 (Suppl A):3-9, 1986.
  21. Chen RT and others. The Vaccine Adverse Event Reporting System (VAERS). Vaccine 12:542-550, 1994.
  22. Measles Outbreak—Netherlands, April 1999—January 2000. Morbidity and Mortality Weekly Report 49:299-303, 2000.

This article was written by John Iskander, MD, MPH, a pediatrician who works for the Department of Health in Columbia, South Carolina.

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This page was revised onAugust 19, 2006.

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