Impact of the thimerosal controversy on hepatitis B vaccine coverage of infants born to women of unknown hepatitis B surface antigen status in Michigan.

OBJECTIVE Hepatitis B vaccine is recommended for all infants, and the series may be started during the delivery admission. For infants who are born either to women who are positive for hepatitis B surface antigen (HBsAg) or to women whose HBsAg status is unknown, vaccination should be started within 12 hours of birth to prevent perinatal and early childhood hepatitis B virus infection. Because of concerns about mercury exposures from vaccines that contain thimerosal, the United States Public Health Service (USPHS) and the American Academy of Pediatrics (AAP) recommended in July 1999 that the first dose of hepatitis B vaccine be deferred until 2-6 months of age but only for infants who are born to HBsAg-negative women. To assess the impact on birth-dose vaccine coverage for infants who are born to women with unknown HBsAg status, we measured coverage before and after July 1999. METHODS A sample of Michigan infants who were born to women whose HBsAg status was either unknown or missing were identified by reviewing newborn screening cards for infants who were born during 1) March-April 1999 (before recommendation changes [T1]); 2) July 15-September 15, 1999 (immediately after recommendation changes [T2]); and 3) March-April 2000 (6 months after resumption of pre-1999 practices were recommended [T3]). We verified maternal HBsAg screening and newborn hepatitis B vaccination by reviewing infant and maternal hospital records. RESULTS Of 1201 infants who were born to women whose HBsAg status was indicated as unknown or missing on the newborn screening card during the 3 time periods, 216 (18%) were born to women whose status was truly unknown at the time of delivery, as determined by medical record review. During T1, 53% of these 216 infants received hepatitis B vaccine before hospital discharge, compared with 7% of infants who were born during T2 and 57% of infants who were born during T3. During T1, 19% of these infants received hepatitis B vaccine within 12 hours of birth compared with 1% of infants who were born during T2 and 14% of infants who were born during T3. CONCLUSIONS Hepatitis B vaccine birth-dose coverage for infants who were born to women whose HBsAg status was unknown at the time of delivery was already low in Michigan before the July 1999 USPHS/AAP Joint Statement but decreased significantly during the 2 months after the USPHS/AAP Joint Statement. Abrupt changes in established vaccination recommendations for lower risk children may lead to decreased coverage among higher risk children. Increases in hepatitis B vaccine coverage at birth are necessary to reduce the risk of perinatal infection for infants who are born to women with unknown HBsAg status.