The Center for Disease Control recently attracted national attention for ending its long-standing recommendation that all newborns receive a standard hepatitis B vaccination. Much less discussion attended a 2022 recommendation from a key CDC advisory committee—which is now being implemented—calling for Hepatitis B vaccinations for all adults ages 19 to 59. Roughly 120 million Americans are newly eligible for the two-to-three-shot vaccinations under the guideline.
Reducing the risk of acute hepatitis B—which produces jaundice and fevers among other symptoms—offers a worthy public health goal. But the main reason for vaccination is to eliminate the life threatening chronic form of the disease, which afflicts roughly 5% of those infected who fail to clear the virus. Much like HIV, the main risk factors are sexual transmission, particularly for men having sex with men, and intravenous drug use with shared needles.
A relative few of my patients have risk of hepatitis B and most of have already been vaccinated. Why would my other patients and the roughly two thirds of Americans between ages 50 and 59 who are married and not intravenous drug users need the vaccine? It’s a fair question and one that the CDC’s Advisory Committee on Immunization (ACIP) glossed over in its recommendation three years ago. ACIP noted that physicians see patients’ willingness to disclose risk factors as a barrier, and many think they have insufficient time to assess risks. In other words, ACIP enables a “don’t ask, don’t tell” policy in which providers won’t need to ask about risk factors and patients don’t have to disclose them. Is that a sound basis for a vaccine recommendation?
Let’s look more closely at the risk issues. For those age 50 to 59, ACIP notes that there has been an increase in the risk of hepatitis B, from 1.1 to 1.6 cases per 100,000. The chances of developing chronic hepatitis B for that group would be just less than one in a million, about equal to the annual risk of being struck by lightning. The chances of dying in an automobile accident in Los Angeles are more than one hundred times greater than this group’s chronic hepatitis B risk. So, the drive across town to get the vaccine may pose more risk than the disease.
I asked a local infectious disease specialist about the recommendations. He advised compliance with the guidelines and noted that we vaccinate against other very low risk conditions. There aren’t many. We do vaccinate against tetanus, which is less common than hepatitis B. However, unlike hepatitis B, tetanus has no easily identified risk factors and is an untreatable condition that is routinely fatal. In an era in which vaccine skepticism based on ignorance is so common, physicians like my colleague may be reluctant to be seen as contributing to the scrum.
The CDC recommendation poses particular problems for primary care doctors like me. Medical systems now track compliance with standard recommendations and insurance report cards may downgrade providers or systems that lag. So offering patients a choice based on their individual risk may be portrayed as sub-standard care. But the issues go beyond the coercive practice of grading providers. A major theme of current medical practice in the wake of COVID-19 is battling unprecedented resistance to critical vaccinations. We already struggle to convince our 50–59-year-olds to stay updated on six different vaccines. Flu vaccine is one example. Despite a national average of 30,000 annual flu-related deaths, we devote precious time and effort to convince vulnerable patients to protect themselves by vaccinating. It helps neither our credibility nor our burgeoning workloads to be compelled to offer yet another vaccine because “that’s the recommendation” or because we don’t trust patients to disclose their risk.
It helps neither our credibility nor our burgeoning workloads to be compelled to offer yet another vaccine because “that’s the recommendation” or because we don’t trust patients to disclose their risk.
The doctors I know resent the actions of the RFK-led CDC in weakening the vaccine mandates that protect Americans’ lives and health. To oppose the hepatitis B recommendation that preceded RFK’s reign might be seen as aiding and abetting the enemy. It’s not. True north for physicians has always been the benefit of the individual patient and the community. The vast majority affected by the hepatitis B recommendations will not benefit. Providing each patient with their own risk and benefit for hepatitis B vaccine should be standard work. When doctors can’t comply with a CDC guidelines in good conscience, the CDC should recognize the need to reconsider this well-intentioned but wrong-headed policy.
Dr. Daniel Stone is Regional Medical Director of Cedars-Sinai Valley Network and a practicing internist and geriatrician with Cedars Sinai Medical Group. The views expressed in this column do not necessarily reflect those of Cedars-Sinai.
