Hi everyone, I’m new to this community, but I have had chronic hepatitis B for many years. I was adopted from China as a baby, and grew up in Toronto, Canada. When I was a kid, they had a school-based immunization program for hepatitis B. I now live in the US, and my understanding is that the US has been doing a universal birth dose since 1991. As an adult, I’ve become more interested in hepatitis B, raising awareness, and the research into finding a cure.
I was surprised to learn most provinces in Canada still have the vaccination program for pre-adolescents, and have not adopted a universal birth dose.
I was wondering why that is, and I did find this paper about universal HBV vaccination in Canada (though it is very old) Moving towards a universal hepatitis B vaccine program for Canadian children - PMC. The paper states that only 3% of reported infections occur in children under 5 years old. I am skeptical of that data, because it’s not clear to me whether it is based on the age at diagnosis, or the age when the infection was acquired. For instance, I was diagnosed at age 12, but doctors said it was likely that I’d had the virus since I was born. Even so, it seems statistically possible that 3% of early childhood infections could develop into something like 25% of chronic infections, based on the fact that infants and children are much less likely to clear the virus on their own.
I’m curious what the experts in this forum think about this policy. I understand that hepatitis B is not endemic in Canada (I think the prevalence rate is similar to the US), but I have also watched lectures from the Hepatitis B Foundation showing that risk-based screening and vaccination is not very effective.
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Hi, welcome, I am fairly new here too.
I have read that most chronic cases are from perinatal transmission.
This article states more than 85%.
https://www.sciencedirect.com/science/article/pii/S1045105617301033
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Hi @et5656,
Welcome to the community. Infants exposed to HBV have a 90% chance of developing chronic infection. I agree with @cholderby. Most of this infection is through vertical transmission or mother-child transmission during birth. The article you shared says it was published in 1995 that was a few years after the vaccines became available. But looking into it there is a birth dose only for infants whose mothers surface antigen was positive, and then a school age dose for those mothers with negative surface antigen. I am unsure why that is the case, but I will agree that they are missing the mark as some infants with negative surface antigen are still at risk of exposure through other household members, peer horse/rough plays, etc.
Most western countries including the US do have a birth dose HBV vaccine program where all infants receive the first dose immediately after birth, the second and third shots in 1-2 and 6 months afterwards. What is lacking is a universal adult vaccination program. The US just adopted this about 2 years ago thanks to the advocacy campaign led by the Hepatitis B Foundation and its partners. The policy used to be that only those at risk were encouraged to get vaccinated, which was not effective. The new policy says any between the ages 19-59.
I hope this helps. Bansah1
Thank you! So it sounds like more advocacy is needed to roll out newborn immunization programs in Canada. It’s kind of shocking that they are still using these guidelines from the 90’s, given how much medicine has evolved. I do think they normally test women for hepatitis B during pregnancy, so many cases would be identified that way. That being said there is also a window when a new infection may not show up on a blood test, so there could always be false negatives, depending on when the test was run.
I think in terms of the math, I was thinking that if you have 100 people newly diagnosed with HBV, according to the stats in that paper, 3 of those would be infants/toddlers, and the other 97 are older children/adults. We know that about 90% of infants will become chronic, compared to 5-10% of older children/adults. So out of the 100, we might end up with 7 people chronically infected – say 2 from the infant/toddler group, and 5 from the adult group. And the other 93 end up clearing the infection. That roughly works out to 25-30% of the chronic infections coming from infant exposure.
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Hi @et5656,
Thanks for raising this topic! I’d love to hear @cscoffin’s input on this.
Essentially, I’d agree with this statement published recently in a commentary from a Canadian colleague in the field Prof Jordan Feld (https://doi.org/10.1093/pch/pxaf024)
Unfortunately, much of Canada is out of step with the 100 + countries that follow the WHO’s recommendation for universal birth dose vaccination, including the USA and Australia .
Thank you for posting this @ThomasTu ! I hadn’t seen that article before. The other thing that is puzzling to me is that some provinces that do have infant immunization programs start these at 2 months old. This actually applies to 4 provinces/territories that do this. The other thing I noticed from the Canadian Immunization Guide link that I put in my original post is that some provinces only administer a total of 2 vaccine doses, when I thought the standard was to do 3.
Side note: I have much respect for Dr. Feld and the whole team at UHN in Toronto. When I lived in Canada, I was a patient there, and I feel like that’s the first place where I was happy with the standard of care I was getting.
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Thanks all
Yes we had advocated for infant or birth dose HBV vaccine recommended in 2007, 2012, 2018 and 2025 Canadian Association for the Study of the Liver Guidelines.
We published an editorial to a paper published by Mia Biondii and Jordan Feld about gaps in prenatal HBV screening.
https://www.cmaj.ca/content/193/1/E26
However I am optimistic there may be policy update next year.
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@cscoffin Any idea why some provinces start the vaccine at 2 months old instead of at birth? It seems to me that not doing it at birth has already missed the most likely time that young children would catch the virus. Is starting at 2 months old really any better than starting in elementary school?
They select 2 months since it is the same time as other infant vaccine schedule (MMR etc). The “rationale” is they do pre-natal screening for HBsAg at birth and should catch any infants at risk of vertical transmission and who would need birth dose vaccine.
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That sort of makes sense. I know some parents are reluctant to give the HBV vaccine to their newborns at birth because they’re worried that the baby is “too young.” I mean, it’s still possible for young children to catch hepatitis B from daycare or school, considering how often kids fall/get hurt, and cut their knee, or something like that.