The recent controversial decision of the Advisory Committee on Immunization Practices (ACIP) in the US to halt universal newborn vaccination with the hepatitis B vaccine has thrust the disease into the public view anew. The specific decision halts mandatory birth immunization of children born to women with a negative HBsAg (hepatitis B surface antigen) screening test and replaces it with shared decision making. In these infants, the first dose of the hepatitis B vaccine can be delayed to two months or older. Routine hepatitis B vaccination at birth will continue for infants born to hepatitis B-infected mothers and those with unknown status. Universal vaccination against hepatitis B at birth is very effective in interrupting infection of the baby and has reduced such infections by over 95 percent. Without vaccination, infants have an over 90 percent chance of contracting chronic hepatitis B from an infected mother.

Since HBsAg is not a perfect marker for hepatitis B infection, many medical societies in the US, including the American Academy of Pediatrics, the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the Infectious Diseases Society of America, have voiced opposition to this new recommendation, and several states are moving to preserve access. HBsAg can be falsely negative in very early infection, in people with very low levels of the virus, and when there is a laboratory error. Exactly what is hepatitis B, and how does this decision affect us in the Philippines?

Hepatitis B is one of several hepatitis viruses that infect human beings. Hepatitis B is a virus that is transmitted through infected body fluids. Common routes of infection include transmission from mother to child during the birthing process, through sexual transmission, through contaminated shared needles, and through infected, unscreened blood transfusions. When someone first gets infected with hepatitis B, they can develop fever, jaundice (yellowing of the skin), and laboratory tests will show elevated liver enzymes. Many people with new infections have a mild or even asymptomatic course. A few unlucky patients can develop liver failure during acute infection, but most people either clear the virus naturally (seroconversion) or develop chronic hepatitis B.

Chronic hepatitis B significantly increases the risk of cirrhosis (liver scarring) and subsequent liver cancer. Cirrhosis is also associated with a high risk of liver failure and bleeding. The risk of developing chronic hepatitis B is highest when hepatitis B is acquired as an infant or in early childhood. Most people who get infected with hepatitis B as adults are able to clear it, but as many as 90 percent of infants who get infected through their mothers will end up with chronic hepatitis B.

Hepatitis B can be treated with antiviral medications such as tenofovir or entecavir. The decision to treat depends on the stage of the disease and how much virus is in the blood. Once started, most patients will need to stay on treatment for life. Fortunately, a highly effective hepatitis B vaccine is available. Three doses are required, including the birth dose, and some people are also given boosters depending on their antibody response.

The Philippines has historically had one of the highest hepatitis B rates in the world. One prevalence study showed that up to 16 percent of Filipinos are HBsAg positive, not counting those who got infected and recovered, and those with very low virus levels. Recent data shows that this has gone down to about 10 percent, still high but improving. The decrease in the number of cases is largely thanks to hepatitis B vaccination at birth and in children. Most hepatitis B in the Philippines is acquired through mother-to-child transmission, and the birth dose of the hepatitis B vaccine is required regardless of the hepatitis B status of the mother.

In the case of a known hepatitis B-infected mother, treating the mother with an antiviral before she gives birth is recommended. This is in addition to a birth dose of hepatitis B immunoglobulin (concentrated antibodies against hepatitis B) plus the birth dose of the hepatitis B vaccine for the baby. Due to the historically high rates of hepatitis B in the Philippines, liver cancer remains a major killer of Filipinos, with some people developing liver cancer as early as their 20s or 30s.

Hepatitis B infection is a major reason for the denial of international employment for prospective overseas workers. Many shipping companies will not accept an HBsAg-positive seafarer since they do not want to take on personnel with potential health risks, and this can mean the end of a Filipino’s dream of working abroad. I have encountered many patients referred to me for clearance due to a positive HBsAg. Some employers will take patients if we start them on treatment and their viral loads become undetectable, but many employers, including those in the household, health, and hospitality sectors, will not.

More tragic than the denial of employment due to chronic hepatitis B are the early cases of cirrhosis and hepatocellular carcinoma (liver cancer) in relatively young people. Sometimes, several siblings are affected and die prematurely from this vaccine- preventable illness. Liver cancer is one of the hardest to treat cancers and carries a poor prognosis.

So, how does the new ACIP recommendation affect us in the Philippines? Due to our high rate of hepatitis B infection, there is no reason to stop giving the birth dose of the vaccine in our setting, regardless of the status of the mother. In fact, one caveat of the ACIP recommendation is that if the mother of the infant is from a high-prevalence region like Southeast Asia, the birth dose should still be offered even if the mother is HBsAg-negative.

The main reason why there is such an uproar among medical societies and physicians in the US, despite their much lower prevalence of hepatitis B, is that whenever a policy has many caveats, there is a higher chance that something will go wrong. Aside from the imperfect performance of HBsAg in identifying mothers with hepatitis B, all the different choices can delay administration of the vaccine in an infant who may truly need it. The consequence of a preventable chronic hepatitis B infection on anyone is potentially catastrophic, and each missed case will prolong the timeline for the elimination of hepatitis B as a public health problem. Those of us in the medical field hope that the current decision will be reconsidered, especially when we know firsthand in the Philippines just how bad hepatitis B can be.