[ozmidwifery] Hep B Vaccine at Birth

[Sandra J. Eales]

I have previously expressed concerns related to the administration of Hep B Vaccine (HBV) to all babes at birth ie that the midwives in my unit had become aware of marked increase in numbers of irritable babes and many more with breastfeeding difficulties in the first few days, since May 2000 when the new schedule was introduced. Since then we have done some investigation and as we became convinced of the connection we have been much more conscientious about gaining "informed consent" prior to administration of birth dose of Hep B ie "full disclosure of risks/benefits without coercion or fraud".  As a result, parents are not consenting and the rate of uptake of the birth dose in our unit has dropped off dramatically.  (It is generally much nicer to come to work these days too with fewer screaming babies, distraught mothers and frantic fathers!) We (the midwives) are now copping flak because we show up very large on the radar in the 'Early Warning System' of the authorities pushing the universal immunisation issue.  The pressure to conform has come from Public Health Unit, District Manager, Medical Superintendent as well as letters of complaint from a local GP (who may be fearful that he will lose his incentive payments if the children who return to hispractice have missedthe birth dose!).  We have been told that we must "actively encourage" our clients to accept the vaccination..that "it is frequently reported that the unit works well because of the high degree of trust and respect. Herein lies the opportunity to disseminate the positive effect of early Hepatitis vaccination"  We have been told that we must "act in line with the Code of Conduct" to actively promote this policy.   I do believe this is a terribly important ethical issue and will not persuade my clients to act against there best interests and instincts.  We use the materials and information provided by Qld Health and "immunise Australia" when we discuss the issue with the parents.It is acknowledged in the "Understanding infant hepatitis B immunisation" pamphlet put out by the "immunise Australia Program" that among the common side effects are mild fever, joint pain, irritability and baby going "off its food for a short time". - discuss how this might affect their newborn in the first few days of life. Whilst these common and perhaps transient side effects may be of little concern in an older child they are liable to be of much greater significance in a newborn child who is already facing many challenges at this deeply important point in its life.  Challenges to the newborn (physiological and iatrogenic pathology) adaptation to extrauterine life – profound physical changes in all systems respiratory, circulatory, neurological, sensory, digestive/alimentary organisation of suck to enable feed overcome effects of pharmacological substances used in labour, birth an postnatally recovery from the traumatic effect of birth eg head moulding and other birth injury We also give them the Qld Health Hep B Information which has this advice "give extra fluids e.g more breast feeds or water"  - we discuss the implication of this at initiation of breastfeeding. We also discuss the risk factors for contracting the disease both in infancy and throught the lifespan.  All women are screened for HBsAg antenatally so that babes of HB positive mothers can receive both Immunoglobulin and vaccination at birth. This has been shown to be extremely effective in managing the risk of vertical (mother to baby) transmission The risk factors (for contracting the disease) are IV drug use, unsafe sexual practices and certain ethnic groups have high endemnicity so may have a slightly elevated risk of transmission (e.g aboriginal, TSI, particular asian groups for whom we have had an effectective 3 dose targetted program for many years). Certain occupational groups, eg health workers, have a higher than average risk and are generally vaccinated witha 3 dose progam. World Health Organisation classifies Australia as a "low" risk for Hep B with low endemnicity of <2%, transmission rates in infancy are "rare" and "infrequent" in childhood. Qld Health Notifiable Diseases Annual Report 1997 -2001 did not count any in the age group of < 13 years. The majority of notifications in the 15 -39 yr age range. WHO recommendation is for universal Hep B immunisation in childhood for those countries with "high" endemnicity and the recommended program is for 3 doses. Immunisation success (90% sero-conversion which is as high as it gets) occurs after the 2nd dose, so a child will become immunised at 4.5 rather than 2.5 months if they choose not to have the birth dose but elect to have the 2,4 & 6 month doses. Breastfeeding rates are not monitored after discharge from hospital even though there are mountains of scientific evidence on the economic value and health benefits to be gained from increasing breastfeeding rates. I wonder if there were pocketable profits to be made from introduction of universal breastfeeding – would the "breastfeeding Nazis" be men in suits with stock options as part of their salary package rather than the mothers at the Austalian Breastfeeding Association coffee mornings? This is a very interesting document which I found in my research. Just go to it to have a look at the last few pages - the attendance list and the Summary of recommendations are truly enlightening. www.vhpb.org/stpetersburg/backgrounddoc/behaviouralissues.pdf It is the report from a 3 day conference in Antwerp which was heavily loaded with members and "invited guests" with addresses and job titles which include the following names - Pasteur Merieux MSD, Smithkline Beecham, Merck, Aventis Pasteur MSD - These people were "junketted" from all around the world to meet and came up with strategic plan on how to push and persuade health professionals, parents, general public and gov't.  I see the language and strategies that came out of this meeting now being employed on me, my colleagues and clients. Eg Early Warning System - to show trouble spots, resistence or "crisis in confidence" Vaccination rates used as "quality issue" Parents being conditioned into belief that any and all vaccination is black and white "Good Parental Practice"   Issues What constitutes informed consent? Coersive and/or fraudulant means for increasing immunisation rates Gagging of midwives and doctors expressing reservations Pressures being brought to bear on health practitioners to conform despite genuine concern and objective assessment Many health professionals have deep concerns about universal Hep B vaccination in childhood and the birth dose in particular.  A 1995 survey of Californian doctors showed that 43% of family physicians and 17% of paediatricians disagreed with the guidelines -that there is no need for it and that it may in fact cause harm. It is also suggested that many of these doctors are giving the vaccine whilst they remain unconvinced that it is in the best interests of their patient because of pressure applied by the HMO that they worked for. The dynamics of the health system are such that health professionals are coerced or bullied into acting against their better judgement.  In Australia doctors receive payments from the federal gov’t for each completed course of vaccination as well as a tiered payment for rate targets eg >85% , >90% of vaccinated kids registered in the practice. Drs in US and UK have similar deals with gov't or employers. Sandra   It would be nice if there were a few more blips showing up on the "Early Warning System"