Is there an argument to be made for turning down the outrage on the hepatitis B vaccine decision?
This is one of those topics that I should just stay away from. I am likely to make everyone angry and give people ammunition (and a quotation) to use against me from the right and left. But I have a cold, I am spending most of the weekend on the couch, so what else am I going to do?
Last week, the ACIP decided, on an 8-3 vote, to change the recommendations for hepatitis B vaccination. The new policy would mean that women who test negative for hepatitis B would decide “when or if” their newborn infant is vaccinated. It seems the recommendation will be to begin hepatitis B vaccination at 2 months. The previous recommendation was that newborns with hepatitis B-negative mothers get their first shot within 24 hours of birth.
The previous recommendation, that children of mothers known to be infected, or whose status is unknown, be immunized within the first 12 hours of life, will not change.1
The mainstream media (NYT, NPR) and many important voices in the vaccine community (Paul Offit, Peter Hotez) strongly opposed the decision. The reasons to oppose the decision include:
The hepatitis B vaccine is safe and effective and has markedly reduced vertical and horizontal transmission of hepatitis B in children.
RFK Jr., though popular based on his commentary on diet and exercise, was appointed based on fringe antivax beliefs. Since his appointment, he has, unsurprisingly, been more active on the anti-vaccines front than on the MAHA front.
The decisions are being made by RFK Jr.’s handpicked ACIP, which includes people with a clear antivax agenda and/or a lack of traditional expertise.
I agree that the decision is wrong. As stated above, the hepatitis B vaccine is effective. It is also safe. As much as the antivax and vaccine-skeptical among us might think, there is zero evidence of harm. Changing the vaccine schedule offers a tiny bit of harm with no benefit.
So, what is the argument to be made to react less vociferously to this change?
First, the harm of making this change is really small. If children get vaccinated a bit later (2 months), the only kids at increased risk of hepatitis B are those whose mothers were recently infected (false negative tests) or those exposed to hepatitis B by household contacts during the first 2 months of life. Add to this that no vaccine is 100% effective, and we are talking about harm to a tiny number of children.
Second, although the vaccine poses no physical harm to a child, our current approach of relentlessly increasing the number of recommended vaccines (up 300% since I graduated from medical school) with little tolerance for personal decision-making has probably caused societal harm. It has, perhaps, helped breed some of the antivax sentiments we are dealing with. Might giving a little bit, in a way that causes little harm, actually help us agree a bit more?
One would argue not to turn down the heat because the answer to my rhetorical question above is almost certainly, “No!”
You can also make the “don’t give an inch” argument. I imagine this going: “RFK Jr. really wants to undermine all our hard-won successes in vaccinating the public. Sure, there is little harm in this change, but if we don’t fight him here, next he comes for polio, MMR, and DTaP.”2 Although I am sensitive to this argument, most slippery-slope arguments are, well, a slippery slope.
Conclusion
I expect we are in for more changes to the vaccine schedule. We are also in for many more strident arguments. I know it is hopeless to ask, but I would like to hear a bit more honesty from both sides. From the RFK Jr. side, I’d love to hear an admission that we have no evidence of vaccine danger. He could argue that the reason to entertain changes is to give people more choice when it poses little risk to individuals or the public in general. He could also stress that the hepatitis B vaccine prevents diseases as diverse as hepatic cirrhosis, esophageal varices, and hepatocellular carcinoma. From the traditional public health community, I’d like some nuance that not every change signals a return to 19th-century levels of infectious disease.
This NYT article gives a pretty summary of the changes that are occurring.
Dr. Cifu, as much as I love and respect you, this has to be one of your worst takes. I don’t understand how someone as logical as you in other medical domains fails to think analytically and free from emotion when it comes to vaccines.
1) when considering any medical intervention (vaccines included) we should always perform expected value calculations to quantify the potential for benefit or harm. The expected benefit of a vaccine is obviously the reduction in probability of infection or serious illness multiplied by the probability of coming into contact with a given illness. In the case of hepatitis b vaccination in babies born to Hep B negative mothers, the chance of coming into contact with the virus is so minuscule that it essentially is akin to multiplying the positive EV side of the equation by a number very close to 0.
2) even if the expected value of HepB vaccination is a small positive, why are we dedicating so much time, energy, and resources to such a small EV endeavor? This is something that drives me mad…in medicine we often hark on these tiny expected benefit interventions simply because (and this is just my opinion) it is easy to implement and monetize. Your time would be better spent reviewing home safety recommendations, sleeping guidelines, post partum depression, smoke exposure, language and motor skill development, and so much more. Yet every time I’m in the hospital caring for a baby born to parents refusing hep b vaccine, I have to go into that room and “counsel” them for 15 minutes about this ludicrous intervention.
I could go on and on regarding this topic but I don’t want to clog up the comment section. I’ve expounded at length on this topic previously and don’t think I can do this topic justice in a comment.
My respect for public health was zero due to the black and white all or nothing catastrophising over effectively non existent risks... I'm not sure that we do have evidence the Hep B at birth vax is safe, I'd love to see the long term morbidity and mortality outcomes from RCT comparing wholly vaxxed (including at birth) and unvaxxed in healthy advantaged children in modern times... they don't exist. My gut feeling is that the margin of error in the safety studies is greater than the putative number of babies that will be harmed by a 2 month delay in vaccination: and that it's similar to the rates of anaphylaxis (one in a million) plus the miscellaneous other rare serious vaccine side effects. Both adverse effects will be of similar magnitude. (Disclosure: as a teenager, my dad died from an in-hospital anaphylaxis - I don't discount that as a risk, don't have the touching faith in crash carts drs seem to, and have been told anaphylaxis is easier to treat in older kids.)
I was completely ignorant of anti vaxxers when I first looked into vaccines as a young parent 30 years ago in NZ, when I was told that delaying vaccines (I had heard anaphylaxis was easier to treat in 1 yo's) would risk my baby's life. I wanted to see how real the risk was - what the absolute risk was. I was a non medical, University educated young mum. Pre the internet, I went to the public library and looked up the last ten years stats for tetanus, a non communicable disease, so no herd immunity argument to muddy the waters. There was also a tetanus vaccine campaign at the time... NZ doesn't have enough tetanus vaccinations, we need more people vaccinated against tetanus. Discovered that in the last 10 years, in NZ, nobody under the age of 70 had died of tetanus, and nobody under the age of 50 had even contacted it. Clearly, with the tetanus vaccine campaign going on, it wasn't because they were all vaccinated. And you're telling me my healthy well-perfused baby is at a realistic risk of dying from tetanus in her first year of life???
This kind of lunatic reasoning is why I lost all respect for the vaccine industry, and I see exactly the same scaremongering and exaggeration of negligible risks in the response to the hepatitis B vaccine shift. Public health advocates treat the public like we're stupid, feed us idiocy, and then wonder why some people react against the catastrophising and decide the health authorities have no credibility. (I shifted from wanting to delay vaccines until my child was a year old, to deciding not to vaccinate at all - because I couldn't believe a word that came out of the mouth of public health authorities.) Incidentally, I saw public health records for the Australian state of NSW (6 million+) - in 10 years, from the mid 2000s onwards, precisely one child died from a vaccine preventable disease on the national childhood vaccine schedule. That's pretty good odds to me, given at least 5% of kids+ are not vaxxed. Far more kids have died in car accidents in NSW, and we don't crucify parents for not restricting their travel to public transport which is much safer. If public health is prepared to accept the fact that parents prioritise convenience over their children's lives when they accept the royal of putting them in a car rather than a train, they should accept that some parents are prepared to tolerate a lesser risk by choosing not to medically modify their children with vaccines.
I'm not arguing vaccination is always bad (I encouraged my daughter to get vaxxed as an adult) but misrepresenting the risks, particularly when contextualised against all the other risks we take with kids, is just stupidity.
The lack of nuance from the vaccine lobby lost my support as a young parent, and that's just being replicated here and now.