Understanding Hepatitis B

SECTIONS of this (lengthy) Overview:

  • Introduction
  • What is Hepatitis B?
  • Hepatitis B Quick Facts
  • Who is Considered “High Risk” for Hepatitis B Infection?
  • Hepatitis B Vaccine History
  • Rate of Hepatitis B Infections in the USA
  • Why Christian Parents Vaccinate
  • Why Christian Parents Delay
  • Why Christian Parents Opt Out
  • A Consideration, Some Common Sense, and Love
  • Sources & Resources

INTRODUCTION
I’m the oldest of 5 children. I recently learned that I was never vaccinated for Hepatitis B (HB), and neither were my first two brothers since we were born before 1991, when the CDC launched a national campaign of adding a recommended 3-dose vaccine series (with the first dose given within 12 hrs of birth) to the childhood vaccination schedule. My 3rd brother, born during the national transition to this new vaccine, was the only one of us to receive the HB vaccine–one dose (not at birth, but at 1 or 2 months–Mom doesn’t remember)–and had a violent reaction. Mom, a nurse, opted to not complete the series for him and passed on it for my sister completely.

After my own research and talking through the Hepatitis B (HB) disease with my mom and other healthcare professionals, I’m convinced that HB is widely misunderstood and that parents should understand the disease as it exists in the United States, risk factors, and the vaccine itself, regardless of vaccine choice.

If you are reading this and were born before 1991 and do not work in the healthcare industry, it’s probable you were never vaccinated either. If you’re a mom or expecting, screening for Hepatitis B infection and immunity is part of your initial blood work early in pregnancy (this is how I found out my status–I’m not immune or vaccinated, but I’ve never been exposed either).

Don’t freak out if you are not immune–like any disease, though this means you’ve probably never been vaccinated (there is a limited 5-10% HB vaccine failure rate), it also means you have made it this far in life without ever being exposed to the real thing (think HIV). If you grew up in a Christian home with a godly heritage, chances are high (99%) your parents and grandparents grew up without being exposed either.

Before rushing to your doctor or local health department to start the 3-shot series, read up on the disease and the vaccine first so that you can make an informed, objective choice either way rather than one based on fear or “just because.” Remember, I’m all about vaccine choice and informed consent. I will not tell you what to do or not do with yourself and your children. If you haven’t already, Read This First: Concerning Vaccines before continuing.

WHAT IS HEPATITIS B?
Hepatitis B (HB) is a liver infection caused by the Hepatitis B Virus (HBV). The HBV is transmitted by percutaneous or mucosal exposure to the blood or body fluids of an infected person, most often through injection-drug use, from sexual contact with an infected person, or from an infected mother to her newborn during childbirth. Transmission of HB also can occur among persons who have prolonged but nonsexual interpersonal contact with someone who is HBV-infected (e.g., household contacts). You can read all about the disease and statistics at the Hepatitis B Foundation and the CDC websites.

Hepatitis B is not spread through casual contact. You cannot get HB from the air, hugging, touching, sneezing, coughing, toilet seats or doorknobs.  You cannot get HB from eating or drinking with someone who is infected nor from eating food prepared by someone who has HB (Hepatitis B Foundation).

HEPATITIS B QUICK FACTS

  • In the USA, HB is not endemic and it is not primarily a children’s disease or one that is a common threat to newborn babies unlike in Asia, Africa and portions of the Middle East where HB is more prevalent. 
  • As of 2013, the national rate of HB infection is 1 in 100,000 persons. (As of 2013, the national rate for HIV infection is 15 in 100,000 persons.)
  • Hepatitis B infections always start classified as acute, but can become chronic. Over 90% of adolescents and adults exposed to the virus recover completely, many with no symptoms. However, 5-10% of exposed adults will develop chronic HBV infection.
  • If exposed, age determines the risk level of developing chronic HB: infants under 12 months have a 90% chance of developing chronic infection, children 1-5 yrs a 25%-50% chance, then drops to 6%-10%.
  • Infections during infancy, while estimated to represent only 1-3% of cases in the USA, account for 20-30% of chronic infections.
  • Once an individual recovers from acute HB, that individual is immune and cannot contract the disease again or infect others. Chronic HBV carriers can infect others–but bodily fluids (semen, blood, vaginal fluids) must enter the body of someone else to cause infection.
  • Most individuals with chronic HB remain symptom free for as long as 20 or 30 years. About 15%–25% of people with chronic HB develop serious liver conditions, such as cirrhosis (scarring of the liver) or liver cancer. Even as the liver becomes diseased, some people still do not have symptoms.
  • The fatality rate for chronic HB cases is 0.5%.
  • On average, symptoms appear 90 days (or 3 months) after exposure, but they can appear any time between 6 weeks and 6 months after exposure. Symptoms usually last a few weeks, but some people can be ill for as long as 6 months. Symptoms include:
    • Abdominal pain
    • Dark urine
    • Fever
    • Joint pain
    • Loss of appetite
    • Nausea and vomiting
    • Weakness and fatigue
    • Yellowing of the skin and the whites of the eyes (jaundice)
  • In the United States, transmission primarily occurs among adults who engage in high-risk behaviors. Transmission to infants and children almost exclusively occurs during the birth process or in the first years of life while the child lives in close contact with an infected household member or with household members who engage in the high-risk behaviors.

WHO IS CONSIDERED “HIGH RISK” FOR HEPATITIS B INFECTION?
Just like any disease, technically anybody can get HBV–but HBV is historically and primarily an adult sexually transmitted disease, transferred by bodily fluids (blood, semen, vaginal fluids). The CDC and secular adult health organizations such as Planned Parenthood classify Hepatitis B as an STD. As such, teens and adults at the highest risk for exposure and infection who are:

  • Sexually active (with multiple partners)
  • Men who have sex with men (and consequently practicing bisexual individuals)
  • Share needles and other “works” to inject drugs

As mentioned before, children at highest risk for exposure and infection to HBV are either born to infected mothers (just like HIV, HBV can be passed on during the birth process) or live in close contact (household) with an acutely or chronically infected person, or lives with individuals who engage in the above high-risk behaviors.

Less common, but still considered risk factors include:

  • Working in the healthcare industry
  • Immigrants from and travelers to high-risk areas
  • Families adopting children from countries where HBV is common (Asia, Eastern Europe, South American and Africa)
  • Sharing razors with an infected person, or getting tattoos and body piercings with contaminated instruments

HEPATITIS B VACCINE HISTORY

  • The HB vaccine is relatively new-the first vaccine was made available to the public in 1982, but mass vaccination strategies were not implemented in the USA or worldwide until 1991-1992. Here is the original 1982 CDC recommendation to vaccinate high-risk adults and only babies of infected pregnant women: Recommendation of the Immunization Practices Advisory Committee (ACIP) Inactivated Hepatitis B Virus Vaccine (CDC, 1982).
  • The mass vaccination goal of the CDC and the World Health Organization (WHO) is not eradication of the disease (like polio & smallpox), but rather elimination of transmission due to the nature of HOW individuals are exposed and infected.
  • Hepatitis B is the first disease transmitted not by casual contact like smallpox or polio, but by high risk behavior such as IV drug use and sexual promiscuity, that has a vaccine mandated for all children.
  • Today there are five recombinant HB vaccines approved by the FDA for use in the U.S.: Engerix-B; Recombivax HB; Twinrix (combined with hepatitis A); Comvax (combined with Haemophilus b Conjugate and meningococcal protein conjugate); and Pediarix (combined with diphtheria and tetanus toxoids, acellular pertussis adsorbed, and inactivated poliovirus). The recombinant HB vaccine is created through genetic engineering of DNA by inserting a segment of the viral gene in a yeast cell.
  • Ingredients: Here’s the CDC’s list of ingredients for all vaccines (last updated Feb. 2015). All Hep B vaccines and combination vaccines contain yeast and one or more forms of aluminum. Other ingredients vary depending on the combination with other vaccines and manufacturer. Engerix-B contains the fewest ingredients, and also does not contain the controversial MRC-5 cells (human fetal diploid cells from a cell line created from the lung tissue of a 14-week aborted baby boy in 1966).
  • The primary reason that the CDC recommended HB vaccination for all newborns in the United States in 1991 is because public health officials and doctors could not persuade adults in high risk groups to get the vaccine.
  • In 1992, the WHO recommended mass world-wide vaccinations. During the mid to late 90s individual states in the USA started adding the 3-shot series as a requirement for daycare and school attendance (here is the CDC Schedule for children from birth-18 yrs old).
  • By 2009, about 41.9% of U.S. adults at risk for hepatitis B infection had received the vaccine and 64.7% of U.S. health care workers had been vaccinated, but the incidence of HB infection among adults had changed little since the period after the vaccine was made available for high risk adults between 1988-1994.
  • The vaccine failure rate is anywhere from 5-10%, meaning after the 3-round series, 18 or 19 out of 20 individuals will attain immunity, and 1 or 2 will not.

RATE OF HEPATITIS B INFECTIONS IN THE USA
Hold your hats for a boatload of numbers! If you want to skip this section, the primary number you need to know is that the national rate of acute HB infection is 1 individual per 100,000 population. All statistics and statements are directly pulled from the latest CDC’s Viral Hepatitis Statistics and Surveillance – United States, 2013, from the “pink book” section on Hepatitis B available on the CDC website (last updated 2015), and the CDC report Acute Hepatitis B Among Children and Adolescents-United States, 1990-2002.

  • In the United States, Western Europe, and Australia, HBV infection is a disease of low endemicity. Infection occurs primarily during adulthood, and only 0.1% to 0.5% of the population are chronic carriers. Hepatitis B became reportable as a distinct entity during the 1970s, after serologic tests to differentiate different types of hepatitis (A, B, C) became widely available.
  • During 1990-2002, a total of 13,829 cases of acute hepatitis B were reported in the United States among persons aged <19 years.
    • The incidence of reported cases declined steadily during this period, from 3.03 per 100,000 population in 1990 to 0.34 per 100,000 in 2002, representing a decline of 89% [note: although an 89% decline sounds impressive, when you look at the numbers in terms of individuals, this is a decrease of 2.5 individuals per 100,000. In other words, mass vaccination of millions of infants is responsible for protecting 2.5 individual high-risk minors out of every 100,000 from an acute infection].
    • The incidence among adolescents aged 15–19 years was consistently higher than the incidence among younger age groups, ranging from 8.69 per 100,000 population in 1990 to 1.13 in 2002.
    • Children and adolescents in all age groups experienced steep declines in incidence during 1990-2002; incidence declined 94% among children aged 0-4 years, 92% among children aged 5-9 years, 93% among those aged 10-14 years, and 87% among adolescents aged 15-19 years.
  • In 2013, a total of 3,050 cases of acute HB were reported from 48 states to the CDC. The overall national incidence rate for 2013 was 1.0 case per 100,000 population. Just as the CDC and the National Vaccine Information Center (NVIC) estimates that only 10% of all adverse vaccine reactions are reported to the VAERS database, the CDC adjusts for under-ascertainment and under-reporting, and estimate that 19,764 acute HB cases occurred in 2013.
  • Of the 48 states that reported acute HB cases in 2013, 31 states had rates below the national rate of 1.0 per 100,000 population. North Dakota reported 0 cases.
  • In 2013, rates were highest for persons aged 30–39 years (2.42 cases/100,000 population); the lowest rates were among children and adolescents aged <19 years (0.03 cases/100,000 population).
  • Data from Enhanced Viral Hepatitis Surveillance Sites (not states), 2013.
    • In 2013, 41 states reported 31,763 case-reports of chronic hepatitis B.
    • Eighteen states agreed to publication of their chronic hepatitis B case data for this report, representing 50.5% (16,044) of all reports of chronic hepatitis B received by CDC in 2013.
    • New York City reported the greatest number of chronic cases (5,857) [note: makes sense, considering population density]. The least number of reports was from the entire state of Montana (21).
    • In 2013, a total of 2,756 chronic hepatitis B cases were reported by six funded sites.
    • Of the six sites, San Francisco reported the greatest number of chronic cases (732, 26.6%) and had the highest rate of chronic HBV infection, with 87.4 cases per 100,000 population.
    • Most (1,802 or 65.4%) cases of chronic HB were among persons aged 25–54 years.
    • Among the 906 cases for which place of birth was known, those born outside of the United States accounted for the greatest number of chronic HB cases (579 or 63.9%). By site, the proportion of reported chronic HB cases born outside of the United States ranged from 46.3% in Philadelphia to 87.0% in San Francisco.
  • The incidence of reported HB peaked in the mid-1980s, with about 26,000 cases reported each year. Reported cases have declined since that time, and fell below 10,000 cases for the first time in 1996. The decline in cases during the 1980s and early 1990s is generally attributed to reduction of transmission among men who have sex with men and injection-drug users, as a result of HIV prevention efforts.
  • During 1990–2004, incidence of acute HB in the United States declined 75%. The greatest decline (94%) occurred among children and adolescents, coincident with an increase in HB vaccine coverage. A total of 2,895 cases of acute HB were reported in 2012, lowering the national rate to less than 1 out of 100,000 individuals.
  • Before routine childhood hepatitis B vaccination was recommended, more than 80% of acute HBV infections occurred among adults. Adolescents accounted for approxi­mately 8% of infections, and children and infants infected through perinatal transmission accounted for approximately 4% each. Perinatal transmission accounted for a disproportionate 24% of chronic infections.
  • Although HBV infection is uncommon among adults in the general population (the lifetime risk of infection is less than 20%), it is highly prevalent in certain groups. Risk varies with occupation, lifestyle, or environments in which contact with blood from infected persons is frequent. In addition, the prevalence of HBV markers for acute or chronic infection increases with increasing number of years of high-risk behavior. For instance, an estimated 40% of injection-drug users become infected with HBV after 1 year of drug use, while more than 80% are infected after 10 years.

WHY CHRISTIAN PARENTS VACCINATE

  • Parents weigh the risks of the disease with potential risks of the vaccine, and decide they want to protect their children from any potential accidental exposure (however small the chance) to the virus.
  • Known exposure to the bodily fluids of an infected individual. Immediate treatment with a vaccine and Hepatitis B immunoglobulin drastically reduces the risk of developing a chronic infection.
  • Mother is infected, or a household member is infected or engages in high risk behavior; therefore, immediate vertical transmission during birth or early exposure risk is high. In these cases, the risks of not vaccinating far outweigh any possible risks associated with delaying or opting out. Even so, parents should be aware that recent studies are revealing that up to 40% of infants born to infected mothers who receive immediate treatment can still develop occult infections early in life, and that it might be worthwhile to investigate the role of antivirals and HBIG administration during pregnancy to prevent mother-to-child transmission of HBV infection.
  • International adoption: internationally adopted infants and children are more likely to be infected. If the adoptee tests positive for chronic HB, or is in the middle of an acute infection (and not yet recovered and immune), vaccination for the rest of the family, especially children under 5, is a consideration.
  • Family is preparing for the foreign mission field in an area where HB is prevalent (8-25% of the population is infected). Transmission is more likely to occur in these areas characterized by poor hygiene, questionable medical care practices, and the general unsanitary conditions of public and private dwellings and places.
  • A household member works with high-risk individuals, when accidental transmission, though still rare, may possibly occur when human error violates the handling of infectious fluid protocol: an STD treatment center, hospital setting, dialysis/diabetes in-patient facility, rehab center, correctional institute, nursing home, etc.

WHY CHRISTIAN PARENTS DELAY

  • Mother is not infected, and no household members or close contacts are infected or engage in high-risk behavior; therefore, no immediate vertical transmission or early exposure risks exist.
  • The infant will not be placed in daycare. Though transmission in a daycare setting is so rare there are no statistics (at least that I’ve found) concerning this risk (though there are a literal handful of documented cases in the past 10 years), it’s still another minuscule risk factor that’s eliminated from the equation.
  • One or both parents have a severe allergy to yeast. The CDC’s HB Vaccine Information Statement specifically says that anyone with a life-threatening yeast allergy should not get the vaccine. This is a “wait and see” response by the parents to understand how the child reacts to yeast before vaccinating.
  • Their infant is premature or child is in poor health. The CDC’s HB Vaccine Information Statement says that “anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine.”
  • Since mass vaccinations of infants didn’t begin until 1991, limited studies on the long-term effectiveness of the vaccine have been conducted, though the CDC states that the vaccine “probably” gives lifelong protection and so far no boosters have been added to the recommended schedule. However, some evidence suggests that vaccine-induced immunity wanes for a very small percentage of individuals as early as the teen years–right when these individuals are more likely to engage in high-risk behaviors. Some parents choose to delay for this reason: if no risk factors exist in the home, they wait until the child is older, educate them on the disease and risk factors, then proceed to vaccinate or give their teen/preteen the option to decide for themselves.
  • Vaccine ingredients concern these parents. They are uncomfortable injecting so many ingredients at once into their infants, regardless of how safe the CDC and doctors say they are. They prefer to wait until their child is older.
  • Because of the extremely low infection rate in the USA, the mode of transmission, and the lack of high-risk factors in the home, parents don’t view the HB vaccine as medically necessary for the health and wellness of their children starting at birth, but may opt to vaccinate in the future dependent upon changes in risk factors.

WHY CHRISTIAN PARENTS OPT OUT

A CONSIDERATION, SOME COMMON SENSE, and LOVE
The consideration of worst-case scenario logic

(Some repeat information): The mass vaccination goal of the CDC and the WHO is not to eradicate the disease (like polio & smallpox), but rather elimination of transmission due to the nature of HOW individuals are primarily exposed and infected. In other words, there will always be cases of infection, because natural man leans toward risky behavior (aka sin) that leads to the consequence of this particular disease. Infants and children exposed at birth or in the home is an unfortunate and sad consequence of adults making poor, irresponsible choices. Take away these risk factors, and in the USA the chance of exposure is practically negligible.

However, governments (at least of “free” nations) and the CDC cannot regulate behaviors (like they say in the USA, “stay out of the bedroom”), so to save the children from the historical consequences of the adults around them, health officials recommend the HB vaccine at birth as a “safety net” (you will see that phrase a lot on the CDC pages and documents concerning the HB vaccine), even for babies born to mothers who tested negative for HB earlier in pregnancy. (Who knows? Maybe the mother had sex with an infected individual later in pregnancy.)

This is a perfect example of the leadership logic I call worst-case scenario logic. Even though a small percentage of infants and children in the USA are at high risk for exposure to this STD, governments and health officials cannot discern who those babies are, and must assume the worst. They assume parents have had multiple sex partners. They can’t always know if a mother/father is lying about drug abuse. They have no idea what kind of household and environment each child will be raised in, where they will travel, who they will associate with. They assume these innocents will grow up and engage in one or more of the high risk behaviors. Nobody should fault governments and health officials for these assumptions.

It’s worst-case scenario logic.

The media and government cannot demand sexual behavior changes from adults (since that would be totally NOT politically correct) and since officials were having a hard time convincing high-risk adults to get the vaccine, the resulting policy of vaccination of all infants is the result of the worst-case scenario logic “safety net.” And it’s a win-win for those in charge: it provides immediate protection for the 2 out every 100,000 infants and children at high risk, provides (they think) long-term protection for an unknown number of the remaining 999,998 who WILL grow up to engage in high-risk activities, and protects the media and government from pointing fingers to the often celebrated sexual lifestyles of teens and adults in the USA.

All this said, you won’t hear about “outbreaks,” “herd immunity,” or statistics in the news concerning HB like you do measles and whooping cough–even though 2,000-4,000 individuals in the USA die each year from chronic liver disease or cancer resulting from the HBV despite vaccination efforts. To bring attention to these figures would also bring to light the consequences of risky behavior–the blame would have to fall on the heterosexual immorality, homosexual lifestyle, or drug abuse of adults who pass the disease on to innocent children or bring it onto themselves.

Some Common Sense
Regardless of whether or not you choose to vaccinate yourself and your children, your choice should never replace common sense. Always treat blood and body fluids–especially of someone you don’t know– as infectious. Hepatitis B is not the only disease transferred by these fluids. There are countless other diseases with NO vaccine and NO cure transferred in similar fashion: HIV, almost all other STDs, and Hepatitis C (blood only), just to name a few.

Love. We are believers in a sovereign Lord, after all!
Regardless of your vaccine choice, as believers we are called to love those around us–even those who choose differently.

  • If you choose to vaccinate for HB, do not fear those who don’t. Millions of people lived without ever being exposed before the vaccine was patented, and millions will continue to do so–vaccinated or not. Also take into consideration that there is no vaccine for HIV, a virus with a higher infection rate in the USA (though still low compared to the rest of the world) and comes with far more serious long-term consequences (AIDS and almost certain early death). Fearing your Christian friends and their children who don’t vaccinate for HB just isn’t logical, considering they, and you, are statistically more likely to be infected with HIV. Short-term and long-term missionaries risk the possibility of accidental infection every day on the field in places like Africa. But the Lord is sovereign over all, even disease, and through careful use of common sense and living sexually pure lives, these missionaries can serve a lifetime without ever being exposed to HIV despite loving and serving infected orphans and adults every day. For these missionaries, love dissolves any fears of HIV and AIDS. For us in the States, love dissolves any fear of Hepatitis B.
  • If you choose to delay or skip out on the HB vaccine, do not judge those who vaccinate. As discussed earlier in this post, there are a variety of logical reasons parents choose to vaccinate for Hepatitis B. Just as millions have lived without the vaccine, millions have and will live vaccinated with no problems. They are choosing what they truly believe is best for their children, as are you…and your choice does not make you closer to God than them.
  • Regardless of choice, be sensitive to others and be willing to have objective, grace-filled discussions. If you vaccinate and find out your pregnant friend is delaying or opting out, find out the why’s before rushing to convince your friend to change her mind. Listen to her logic and her story. If you do not vaccinate or you delay, don’t run around telling all your mommy friends to do the same in regards to the HB vaccine. There are some legitimate reasons for some newborns to get it! Instead of throwing a bunch of vaccine articles at your friends, simply ask why they feel the HB vaccine is important at birth. If they’ve never thought about it and don’t really know, that opens to the door for an objective discussion about why you made your choice, rather than stuffing your decision up their nose.
  • Parents who’ve made up their minds usually don’t change them. If you vaccinate, chances are you won’t change the minds of your friends who don’t, and vice versa.
  • For you undecided parents out there, who like to research things out and are looking for objective and middle-of-the-road information, I hope you found this Hepatitis B overview helpful!

SOURCES and RESOURCES
I tried to make sure that every article I reference and every website I consulted is listed below. If at any time you find a dead link, please let me know! This brief overview is by no means exhaustive of all the information and statistics out there, so hopefully for those who want to know more find this section helpful.

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