Letters to the Editor

Indian Pediatrics 2002; 39:981-982

First Dose of Hepatitis-B Vaccine (HBV) in Infants

This is with reference to the new guidelines for Hepatitis-B Vaccine (HBV), in the "IAP Guide Book on Immunization" published by the Committee on Immuniza-tion, Indian Academy of Pediatrics in 2001(1). Though it is mentioned in the Guide Book that the recommendation is to give the first dose of HBV at birth, the schedule given on page 29, and the IAP Immunization Time Table given on page 47, give the impression that giving the first dose at birth or at 6 weeks are equally acceptable. Whether this ambiguity is intended or not, it has already caused some avoidable confusion adversely affecting the impact of HBV in infants. This note is to caution against such unnecessary ambiguities.

It has been widely accepted that one of the best methods to eliminate Hepatitis B from a population is by minimizing perinatal transmission from mother to the newborn with the use of HBV soon after birth. The ideal way to do this is to screen all pregnant women for HBsAg and making sure that the newborns of positive mothers get HBV as soon as after birth, ideally along with HBIG. One may postpone the first dose if the mother is found to be negative. And if all women are not being screened, it is recommended that all newborns are immunized soon after birth. Since not all pregnant women are screened for HB in our country, any ambiguity in the Guide Book which gives the mistaken impression that the first dose of HBV given at 6 weeks or at birth as equally acceptable, should be avoided.

The fact that most children in India are not born in hospital may be given as a caveat for the new recommendation. But that fact has not deterred anyone from recommending the first dose of OPV or BCG soon after birth. What should be recommended as ideal should not be contingent on circumstances, though we may act based on the circumstances of the patient. If at all any immunization has to be given at birth, it is HB. Birth itself is a risk-factor in its causation as the mother could be the source of infection and the conditions for contamination at birth an easy means of transmission. Even without such temporal and causal relation to brith, both BCG and the first dose of OPV are recommended at the time or soon after birth to emphasize the importance of giving them as early as possible. The new recommenda- tion diminishes this emphasis of early immunization with HBV with no reason at all.

In many parts of India, where most of the children are born at home, this recommendation may not make much of a difference. But in Kerala, where almost all births are in hospital, and where not all pregnant women are screened for HBsAg during pregnancy, postponing the first dose of HBV to 6 weeks is not just inadvisable but indeed harmful. Based on the new recommendations, some hospitals in Kerala have already printed new Immunization Cards where the first dose of HBV is shown to be given at 6 weeks along with DPT. It will be unfortunate if even a single child born in such a hospital acquires Hepatitis B from the mother because the child did not get the HBV soon after birth but only later at 6 weeks; indeed a case of closing the barn after the horses are gone.

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