Rapid Responses to:

Jangu Banatvala, Pierre Van Damme, and Nedret Emiroglu
Hepatitis B immunisation in Britain: time to change?
BMJ 2006; 332: 804-805 [Full text]
*Rapid Responses: Submit a response to this article

Rapid Responses published:

 Rapid Response] Universal Hepatitis�B Vaccination in India: A Questionable Strategy
Peter R Mansfield, Anant Phadke and Ashok Kale   (8 April 2006)
 Rapid Response] Relevant
John Stone   (10 April 2006)
 Rapid Response] Universal immunization with Hepatitis B: Keeping up with the Joneses
Jacob Puliyel, Amit Kumar   (14 April 2006)
 Rapid Response] WHO can be confident about multiple vaccines in infancy?
Wouter Havinga   (22 April 2006)

Universal Hepatitis�B Vaccination in India: A Questionable Strategy 8 April 2006
Previous Rapid Response Next Rapid Response Top
Peter R Mansfield,
Director, Healthy Skepticism Inc
34 Methodist St, Willunga SA 5041, Australia,
Anant Phadke and Ashok Kale

Send response to journal:
Re: Universal Hepatitis�B Vaccination in India: A Questionable Strategy

We agree with Banatvala, Van Damme and Emiroglu that adequate economic analysis of universal hepatitis B vaccination is required before recommending policy change in Britain.<1> In India, plans for universal hepatitis B vaccination have been announced without an economic comparison against other programs that may be more cost effective.

The marginal cost-efficacy of hepatitis B vaccine in India has been estimated,<2> but has not been compared with investing in the current Expanded Programme of Immunisation (EPI), which currently achieves complete primary immunisation of only 35% of eligible children.<3> Hepatitis B vaccine is more expensive than the combined cost of the vaccines for the six other diseases covered by the current EPI. These six diseases: measles, diphteria, pertussis, tetanus, polio and tuberculosis probably cause more harm than hepatitis B.

The World Health Organisation recommends universal hepatitis B vaccination when hepatitis B carrier rates are above 2%.<4> The oft quoted estimate for India of 4.7% is based on incorrectly pooling results of a set of studies including unrepresentative high risk groups and equating the single test HBsAg positivity rate with the carrier rate. Correcting these errors yields a carrier rate of 1.42%.<5>

In India the most important mode of transmission for hepatitis B is perinatal. Prevention of perinatal transmission requires that newborns be given the first dose of the vaccine within 12 hours of birth. However in India the majority of births take place at home where the logistics of timely vaccine delivery are beyond India�s resources. Consequently the majority of newborns (the most vulnerable group) will not be protected from perinatal transmission by 'universal' vaccination.

In developing countries like India an open debate, informed by accurate data and thorough economic analysis of competing priorities, is needed before a final decision is taken about universal hepatitis B vaccination.

1. Banatvala J, Van Damme P, Nedret Emiroglu N. Hepatitis B immunisation in Britain: time to change? BMJ 2006;332:804-805 (8 April), doi:10.1136/bmj.332.7545.804

2. Aggarwal R, Ghoshal UC, Naik SR. Assessment of cost-effectiveness of universal hepatitis B immunization in a low-income country with intermediate endemicity using a Markov model. J Hepatol. 2003 Feb;38(2):215-22.

3. National Family Health Survey (NFHS II), 1998-98, IIPS MACRO, table 6.9, p 204.

4. Ghendon Y. WHO strategy for the global elimination of new cases of hepatitis B. Vaccine. 1990 Mar;8 Suppl:S129-33

5. Phadke A, Kale A. HBV carrier rate in India. Indian Pediatr. 2002 Aug;39(8):787-8

Competing interests: None declared

Relevant 10 April 2006
 Next Rapid Response Top
John Stone,
London N22

Send response to journal:
Re: Relevant

Of great relevance to this article is another by Marc Girard in the latest issue of Journal of American Physicians and Surgeons: "World Health Organization Vaccine Recommendations: Scientific Flaws or Criminal Misconduct?" Dr Girard, an expert witness in the French Courts, presents evidence that the WHO have greatly exaggerated the danger to population from Hepatitis B while the vaccine "benefits are overstated and toxicity greatly understated". He also notes that the WHO's "influenza vaccine recommendations falsely imply that the available vaccines could help prevent avian influenza" [1].

I also note that the WHO infant schedule for 0-14 weeks which includes Hepatitis B injects 0.1875 mg of mercury, hundreds of times the US Environmental Protection Agency guideline [2].

[1] http://www.jpands.org/vol11no1/girard.pdf

[2] John Stone 'Mercury and Autism in the U.K.' Red Flags, 1-6 February 2006, availble at: http://www.jabs.org.uk/pages/article1.doc

Competing interests: Autism parent concerned about excessive use of vaccine

Universal immunization with Hepatitis B: Keeping up with the Joneses 14 April 2006
Previous Rapid Response Next Rapid Response Top
Jacob Puliyel,
Head of Department of Pediatrics
St Stephens Hospital, Tis Hazari, Delhi,
Amit Kumar

Send response to journal:
Re: Universal immunization with Hepatitis B: Keeping up with the Joneses

Universal vaccination of all in the UK with Hepatitis B vaccine will reduce the yearly incidence of new cases of chronic carriers by a mere 4%. 96% of the burden of disease results from disease in immigrants who will not be helped by universal immunisation in the UK. Although these stark facts are widely known (1), in the space of a little more than a year, we have had two editorials in the BMJ, (authored by individuals with declared conflict of interests) suggesting that the UK government must adopt a policy of universal immunisation (2, 3). The latest editorial (3) says that 168 countries worldwide and 44 of 52 countries in WHO's European region have already implemented this policy.

It will be interesting to see at what critical mass of editorial badgering, the government will be persuaded against its better judgement, to undertake this wasteful programme � just to keep up with the Joneses


1. Foundation for Liver Research. Hepatitis B: out of the shadows. London, Foundation for Liver Research, 2004. www.ucl.ac.uk/liver- research/hepatitis-report.pdf

2. Beeching NJ Hepatitis B infections BMJ 2004; 329: 1059-1060

3. Banatvala J, Damme PV, Emiroglu N. Hepatitis B immunisation in Britain: time to change? BMJ 2006;332:804-805

Competing interests: None declared

WHO can be confident about multiple vaccines in infancy? 22 April 2006
Previous Rapid Response  Top
Wouter Havinga,
sessional GP

Send response to journal:
Re: WHO can be confident about multiple vaccines in infancy?

Banatvala et al mention the anxiety some people feel about giving multiple antigens to babies and say this is unfounded but do not offer any references to support their confidence in the safety of giving multiple vaccines in infancy.1

However, evidence suggests that the Th1-Th2 balance of the immune system can be primed in infancy to favour Th2 responses in later life.� Antigenic exposures in infancy are associated with permanent distortions of the TH1/Th2 balance. 2 Vaccines contribute to these exposures.� The Th2-profile is associated with an allergic phenotype.

What can explain the dramatic increase, over the last decades, of chronic non-communicable diseases such as asthma, eczema and hay fever? With vaccines the body is triggered into developing antibodies. Could the immune system be trained, for example in the UK due to the vaccines in month 2, 3 and 4 to respond with antibodies to an allergen as in atopic diseases? And as in every training, the result will be more consolidated with increasing intensity? Research is needed into this concept of priming the immune system in early childhood towards a Th2-profile. Renz et al urge for clinical and epidemiological studies to evaluate the impact of TReg cells in different periods of life. Foremost studies are needed following the maturation of the immune system from birth.

The increase in allergic diseases is running parallel with the steady increase in the number of vaccines over the last decades. This observation calls for each country�s Public Heath Department to compare the morbidity and mortality figures of prevented acute infectious diseases through vaccines, with current increased numbers in mortality and morbidity of non-communicable diseases.

WHO can be reassured and confident without these figures and studies and without an open discussion on early childhood vaccinations and the TH1/TH2 balance?

1 Banatvala J, Van Damme P, Emiroglu N. Hepatitis B immunisation in Britain: time to change? BMJ��2006;332:804-805

2 Renz H, Blumer N, Virna S, Sel S, Garn H. The immunological basis of the hygiene hypothesis. Chem Immunol Allergy. 2006;91:30-48

Competing interests: None declared