Expert calls for Hep B vaccines at birth in Ontario, saying kids are falling through the cracks

A leading liver expert is calling on the Ontario government to re-evaluate its hepatitis B vaccination strategy, saying some children are falling through the cracks and getting diagnosed with hepatitis B virus (HBV) before vaccines are offered at age 12.

That puts them at high risk for a life of chronic illness and even liver cancer that could have been prevented, says Dr. Jordan Feld, director of the Toronto Centre for Liver Disease at the University Health Network and a senior scientist at Toronto General Hospital Research Institute. He wants Ontario to follow international guidance and vaccinate children at birth.

His comments come amid an outcry in the United States after a Centres for Disease Control panel, appointed by Health Secretary Robert F. Kennedy Jr., voted to scrap birth doses of the vaccine. That decision has been heavily criticized by experts, who say the change is not based on science and will put children at risk.

The U.S. debate represents a key moment for Ontario officials to consider updated information and re-evaluate the timing of the vaccine here, Feld says.

The U.S. introduced hepatitis B vaccination for all newborns in 1991, something the World Health Organization still recommends. Since then there has been a dramatic drop in new HBV cases among children and teens: a 94 per cent drop in new cases for children from birth to age four between 1990 and 2002, and an 89 per cent drop for everyone under 19.

In Alaska alone, new cases of HBV have been eliminated since the introduction of doses at birth, Feld said, and no new cases of liver cancer have been reported there since 1999.

In Canada, the National Advisory Committee on Immunization recommends hepatitis B vaccination for all infants and children under age 18. All provinces offer it as part of their childhood vaccination schedules, but they do so at different times.

New Brunswick, Nunavut and Northwest Territories all administer the vaccine within an infant’s first 24 hours of life. British Columbia, Alberta, Quebec, Yukon and Prince Edward Island all offer it at two months of age. Ontario, Saskatchewan, Manitoba, Nova Scotia and Newfoundland give it to adolescents at age 12.

In additional to the Grade 7 school-based program, Ontario has a program for people of any age who are considered high-risk, says W.D. Lighthall, spokesperson for the Ontario Ministry of Health. Prenatal hepatitis B screening and at-risk infant immunization is part of the program, he says.

The province’s hepatitis B vaccine strategy is based on a number of factors, Lighthall says, including burden of disease, vaccine characteristics such as effectiveness and safety and expert recommendations.

But more has been learned about the vaccine and the impact of timing since the strategy was launched, Feld says. He was part of a team that published studies looking at the effectiveness of the vaccination policy.

Among findings was that a number of children born in Ontario were falling through gaps, getting infected with the virus before they had a chance to get vaccinated as adolescents. The research identified 139 children over 10 years, but Feld says that represents just the tip of the iceberg because there is no routine testing for hepatitis B and it can be asymptomatic for many years. Those who were tested and identified were the “lucky ones”, he says.

He says the decision to vaccinate children as adolescents may have been partly based on a concern, at the time, that the vaccine would not be effective into adulthood if given at birth. It is now known that the vaccine remains effective into adulthood.

Feld says a key reason birth doses make such a difference is that the outcomes when infants are infected are significantly more severe than for those infected later in life. A baby who is infected has a 90 per cent chance of developing a chronic infection that can lead to liver failure or cancer. That is generally not the case in adults, he says.

Feld was part of a team that found shifting to birth doses was not only good public health policy, but was also cost-effective.

According to Feld, the decision to end universal birth doses in the U.S. was both misinformed and driven by a general skepticism about childhood vaccines.

“This U.S. has made a bad decision and we should take that as an opportunity to act on the data that we have that would recommend we move to birth dose vaccination,” he says.

He adds many Canadians watching the U.S. debate are likely surprised to learn that birth-dose vaccinations are not universal in Canada, as they were in the U.S. before the recent decision.

“We often assume we are doing things in line with international guidelines and thinking carefully about public health,” he says.

Feld would like to see a national recommendation in favour of birth doses instead of the current guidance that recommends all children and youth under 18 be vaccinated, but leaves the exact timing up to provinces.

“If your vaccine policy is proving ineffective and children are getting infected prior to vaccination, then the policy should be revisited,” Feld says.

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