October 9, 2001

Give the Birth Dose!
Providing all infants with hepatitis B vaccine
at birth saves lives.

The Immunization Action Coalition (IAC) urges each of the organizations listed above to support the establishment of a national policy to protect ALL infants from hepatitis B virus (HBV) infection by requiring that the first dose of hepatitis B vaccine be administered to every infant at birth and no later than hospital discharge.

Approximately 19,000 women with chronic hepatitis B infection give birth in the United States each year. Ninety percent of perinatal infections can be prevented by postexposure prophylaxis given within 12 hours of birth. Tragically, many babies are exposed to HBV at birth but do not receive appropriate postexposure prophylaxis.

Because thimerosal has been removed from all pediatric hepatitis B vaccines in the United States, concerns about thimerosal should no longer be an obstacle for practitioners in enacting a universal birth dose policy.

Why is such a policy necessary? Following are some of the ways infants who are not vaccinated at birth become infected:

• The pregnant woman is tested and found to be hepatitis B surface antigen (HBsAg)
  positive, but her status is not communicated to the newborn nursery. The infant receives neither hepatitis B vaccine nor HBIG protection at birth.
     
• A chronically infected pregnant woman is tested but with the wrong test, HBsAb (antibody to hepatitis B surface antigen), instead of HBsAg. This is a common mistake since these two test abbreviations differ by only one letter. Her incorrectly ordered test result is "negative," so her doctor believes her infant does not need postexposure prophylaxis.
      
• The pregnant woman is HBsAg+ but her test results are misinterpreted or mistranscribed into her prenatal record or her infant's chart. Her infant does not receive HBIG or hepatitis B vaccine.
     
• The pregnant woman is not tested for HBsAg either prenatally or in the hospital at the time of delivery. Her infant does not receive hepatitis B vaccine in the hospital even though the vaccine is recommended within 12 hours of birth for infants whose mothers' test results are unknown.
     
• The woman is tested in early pregnancy for HBsAg and is found to be negative. She develops HBV infection later in pregnancy but it is not detected, even though it is recommended by CDC that high-risk women be retested later in pregnancy. The infection is not clinically detected by her health care provider so her infant does not receive hepatitis B vaccine or HBIG at birth.
       
• The mother is HBsAg negative but the infant is exposed to HBV infection postnatally from another family member or caregiver. This occurs in 2/3 of the cases of childhood transmission.

The following table summarizes the arguments for the birth dose vs. a two-month visit dose of hepatitis B vaccine. While there are advantages to giving the first dose at a later well-baby visit, these are advantages of administrative convenience. The primary advantage of giving the first dose at birth is that it saves lives.

Advantages of the Birth Dose vs. Two-Month Visit Dose

Birth Dose Advantages

Two-Month Dose Advantages

Hepatitis B vaccine at birth prevents disease and saves lives. It protects: infants whose mothers are HBsAg+ but the information is not communicated to the newborn nursery. infants whose mothers were never tested. infants whose mothers' HBsAg tests were ordered incorrectly, mistranscribed, or misinterpreted. infants whose mothers became HBsAg+ later in pregnancy. infants with limited or no postnatal care. infants exposed to HBV during the first 2 months of life. Hepatitis B vaccine administration in the hospital increases likelihood that all immunizations as well as the hepatitis B vaccine series will be completed on schedule.           Hepatitis B vaccine provides an early opportunity to convey the importance of immunization to parents.

Administration in the office setting may cost less than administration in the hospital.        Convenience: It is easier to keep track of all doses of vaccine administered in the office. (No need to obtain and review hospital records to determine if previous vaccine doses were given.)         A combination vaccine can spare the infant one injection.

IAC recently asked hepatitis coordinators at every state health department as well as at many city/county CDC projects to express their views about providing hepatitis B vaccine in the hospital. Their responses contained many examples of children who were unprotected or inadequately protected due to not ordering, misordering, misinterpreting, mistranscribing, and miscommunicating the hepatitis B test results of their mothers. In order to overcome these failures, the states overwhelmingly endorse providing a birth dose.