Unacceptable Risk

Texas health officials say that mandatory childhood vaccinations against hepatitis B will prevent the spread of life-threatening illness. But which is riskier--the disease or the vaccine?

The hepatitis B virus represents at least three firsts in U.S. immunization policy. It's the first "adult behavior" disease for which children are routinely immunized; it's the first vaccine for a disease that, relative to almost everyone else in the world, Americans aren't at high risk to contract; and it's the first genetically engineered vaccine to appear on the CDC's recommended schedule of childhood immunizations.

Until about 1990 the CDC hadn't made much of a federal case out of hepatitis B, focusing on the spread of the virus among health-care workers, intravenous drug users, and gay men. When the CDC announced its "comprehensive strategy" for eradicating hepatitis B through universal childhood vaccination in 1991, the agency cited unpublished in-house studies that concluded that vaccinating only high-risk groups had failed.

The CDC justified its new strategy by claiming that the disease had infected an estimated 200,000 to 300,000 people each year between 1980 and 1981, and that approximately 4,000 to 5,000 people die each year from hepatitis-related liver disease.

The accuracy of those estimates is questionable. Between 1988 and 1992, the number of hepatitis B cases reported nationwide decreased by 50 percent, according to the CDC's National Health and Nutrition Evaluation Survey. Moreover, infection rates among children under the age of 16 constituted only a small percentage of the total. Also, numerous scientific studies, including one commissioned by the World Health Organization, reported that the incidence of hepatitis B around the world was at an all-time low, primarily because those at highest risk had modified their behavior in response to the HIV pandemic.

The agency's subsequent expansion of its recommendations regarding hepatitis B also defied reason. For example, in 1993, 63 percent of hepatitis B cases occurred in adults. Yet two years later the CDC expanded its recommendation to include mandatory hepatitis B vaccination for 11- and 12-year-olds. In 1997 the agency expanded its recommendations yet again, this time to all people under age 18.

Today, public-health officials are optimistic that hepatitis B will someday be eradicated through universal childhood immunization. But less than two years ago, before most states, including Texas, implemented their vaccine mandates, the CDC itself suggested that perhaps the strategy they had once relied upon--targeting high-risk groups--really hadn't failed at all.

In an October 1997 issue of Morbidity and Mortality Weekly Review, a publication of the CDC's infectious-disease division, the agency reported what many people have always believed was true: "Hepatitis B continues to decline, primarily because of a decrease in the number of cases among injecting drug users and, to a lesser extent, among both homosexuals and heterosexuals of both sexes."

Glenda Matheny is happy to hear that, but understandably it makes her angry. Why didn't the people who now force every child in Texas to be vaccinated against hepatitis B--the people who, as public-health experts, presumably want to protect children--know this?

"As a parent, I should have been made aware that my daughter really wasn't at risk," Glenda says. "But now I realize that they really don't know the full implications of what they're doing with this vaccine.

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