Hospitals across New York struggle to vaccinate newborns against deadly hepatitis B virus

Many New York hospitals struggle to ensure that newborns are vaccinated against the hepatitis B virus prior to leaving the hospital, potentially putting those who are not vaccinated at increased risk of contracting a virus that kills more than 700,000 people worldwide each year.
A New York World review of data released by the state Department of Health (DOH) revealed that more than half of state’s birthing hospitals reported vaccinating less than 90 percent of newborns against hepatitis B before they were released from the hospital in 2013, failing to meet standards set by the state in 2006 that called for universal vaccination within 12 hours of birth.
At a handful of hospitals across the state, the vaccination rate was below 55 percent.
The state data do not include hospitals located in New York City, but a report last year found that in 2012 many city hospitals, including Mount Sinai Hospital, New York Presbyterian’s Weill-Cornell Medical Center, and Mount Sinai Beth Israel Hospital, were vaccinating less than 50 percent of infants.
“When babies are vaccinated before they leave the hospital, it’s a safety net,” said Sarah Schillie, head researcher of the U.S. Centers for Disease Control and Prevention’s hepatitis B vaccine unit. “When an infant gets a hepatitis B infection, about 90 percent of the time it leads to a chronic infection. And 25 percent of those who are chronically infected as an infant die earlier than expected from cirrhosis of the liver or liver cancer.”
A 2013 state-by-state survey of vaccination rates conducted by the CDC found that New York state ranked 45th in the country in the percentage of infants given the vaccination within three days.
The CDC survey found a statewide vaccination rate of 64 percent. DOH officials say that while the survey is “a good tool,” it underestimates the percentage of newborns receiving the vaccine.
DOH data, which excludes New York City, puts the rate at closer to 80 percent.
City health officials declined to comment for this story or provide updated vaccination rates for city hospitals.
The hepatitis B virus is 100 times more infectious than HIV and has no known cure. It invades the liver by tricking the body’s cells into making more copies of the virus. Chronic infections can cause serious liver damage that can sometimes trigger cancer.
Of the 40,600 cases of chronic hepatitis B reported in the U.S. in 2012, close to a third—13,000—were reported in New York state. And 12,000 of those cases were reported in New York City.
Experts say that relatively high number of hepatitis B cases in New York is likely related to the state’s large Asian population. According to the CDC and other health groups, hepatitis B is far more common among Asian Americans and Pacific Islanders than in the general population. One in 12 Asian Americans in the U.S. is affected by the disease, compared with less than 1 percent of the general population affected by a chronic infection.
“Hepatitis B tests are complicated,” said Deborah Wexler, executive director of the Immunization Action Coalition. “There are several blood tests for hepatitis B that are used when determining whether a person is infected or not. To further complicate the matter, a variety of abbreviations are used for these different tests which can lead to provider confusion when ordering or interpreting test results. This has resulted in medical errors which have led to newborns becoming chronically infected with hepatitis B.”
And while a significant percentage of those who did not receive the first of three doses of the vaccine prior to leaving the hospital likely were inoculated later, Wexler said that, for those babies who aren’t vaccinated before discharge, delaying vaccination even for as little as three days can lead to babies becoming infected if they were exposed to hepatitis B at birth or to an infected person at home
While the hepatitis B vaccination is not required, the CDC, American Academy of Pediatrics and other public health groups recommend that all babies get the inoculation before they leave the hospital.
A 2012 report published by New York City’s Department of Health found that around 2,000 babies were born to mothers infected with the disease, nearly 2 percent of all newborns in the city that year. Of those born to infected mothers, 22 percent were not tested at all for the disease.
Public health officials in New York have made efforts to improve hepatitis B vaccination rates, including a program launched in 2003 that offered to provide free doses of the vaccine to hospitals that agreed adopt a “universal hepatitis B birth dose policy.” According to DOH documents, every hospital in the state enrolled in the program by 2008.
And in 2006 the DOH issued new standards calling for every newborn to receive the first dose of the vaccine within 12 hours.
However, despite those efforts, many hospitals continue to struggle in inoculate newborns.
During interviews, public health experts, doctors and hospital officials offered several possible explanations for the state’s struggle to inoculate newborns, including lax hospital policies and turf battles between the hospitals and pediatricians.
Chari Cohen, director of public health for the Hepatitis B Foundation, said she’s encountered pushback from pediatricians.
“It’s very unfortunate, because instead of having a turf war we should be worried about preventing infection,” she said. “It’s really all about the health of the baby.”
Winthrop-University Hospital on Long Island had a newborn vaccination rate of 50 percent in 2013. Leonard Krilov, vice chairman of pediatrics and chief of pediatric infectious diseases at the hospital, said the current rate is up around 66 percent for 2014, but said the low rate is largely due to mothers arranging to vaccinate their baby later, with their private pediatrician, not lack of education about the vaccine, or vaccine resistance.
Krilov said that after the state published recommendations in 2006, there was resistance from some pediatricians.
“Initially there was a pushback from the private pediatricians even though there was this state standard,” he said. “They wanted to hold on to their turf, but as the writing of the standards became clear they started to come around.”
Elie Ward, executive director of the American Academy of Pediatrics’ New York City chapter, said that hospitals are “blowing smoke” when they blame their low vaccination rates on private pediatricians.
“Most pediatricians want babies vaccinated before they leave hospitals,” she said. “And if it was just the pediatricians, then why would two hospitals that are close together have drastically different rates if they have the same group of pediatricians around? It doesn’t make sense.”
Ward said that it’s up to the hospitals to encourage parents to vaccinate their babies before leaving the hospital. She said some hospitals—she wouldn’t name specific ones—don’t have the appropriate policies, or just don’t implement them properly.
“Hospitals are all unique,” she said. “They’re like people. Their systems are unique, and they’re run by people. And they tend to defend themselves when they’re asked questions they can’t answer.”
Tammy Chaffee, nurse manager of women’s health services at Jones Memorial Hospital in Allegany County, where the hepatitis B vaccination rate was 51 percent for newborns in 2013, said that when pregnant mothers are admitted to the hospital they are given a vaccination information sheet and advised by a nurse. Mothers also have to sign a consent agreement for the hepatitis B vaccine, and if they refuse, they have to provide a reason, which the hospital documents.
“Primarily, patients who refuse vaccination at the hospital decide to vaccinate at their pediatrician’s office,” she said. “A lot of times it’s just personal preference. They want more info from pediatricians. They want to ask more questions, and they’re more comfortable waiting until the baby is older.”
Eric Beyer, a pediatrician who works for the Canandaigua Medical Group near Rochester, said that most pediatricians he knows encourage mothers to vaccinate their babies at the hospital. He also said that with an initiative like the one New York is trying to implement, there’s bound to be resistance.
“There’s an adage that says that any change in science takes about 17 years to implement in practice,” he said. “So anytime there’s an initiative to do something new, there’s always cultural crosscurrents from doctors and nurses who are used to doing things another way.”
By Roger Miller, The New York World

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